
Class _SJ_4£ 
Book_^_S_44_ 



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COP/RIGHT DSPOSI& 



DISEASES OF CHILDREN 



DISEASES OF CHILDREN 

DESIGNED FOR THE USE OF STUDENTS 
AND PRACTITIONERS OF MEDICINE 



BY 

HERMAN B. SHEFFIELD, M.D. 

Formerly Instructor in Diseases of Children, Xew York Postgraduate Medical School 

and Hospital, and Medical Director, Beth David Hospital, Consulting 

Physician to the Jewish Home for Convalescents and the 

East Side Clinic for Children. 



WITH 238 ILLUSTRATIONS, MOSTLY ORIGINAL, 
AND NINE COLOR PLATES 



ST. LOUIS 

C. V. MOSBY COMPANY 

1921 






Copyright, 1921, By C. V. Mosby Company 

(All rights reserved) 



Printed in the U. S. A. 



JUN -6 1921 



Press of 

C. V. Mosby Company 

St. Louis, U. S. A. 



©CI.A617214 



^> 



TO THE MEMORY OF HIS BELOVED SON 

ROBERT LEONTE 

THIS VOLUME 

IS AFFECTIONATELY DEDICATED 

BY THE AUTHOR 



PREFACE 



This volume is the consummation of the author's experience in the 
field of pediatrics for nearly thirty years. It embodies the latest knowl- 
edge of the theory and practice of the diseases of infancy and childhood 
and is designed to meet the needs especially of the general practitioner 
and medical student. 

The book is conveniently divided into fourteen sections, the classifica- 
tion of the diseases varying somewhat from that of older textbooks, so 
as to correspond to the modern conception of the causation of the dis- 
eases in question. 

Infant feeding is based upon the most recent studies of the digestibil- 
ity of proteins, fats and carbohydrates and upon the author's practical 
experience. The fads and fetichisms of the erratic reformer and senile 
reactionary are eliminated. Breast feeding is recommended in prefer- 
ence to bottle feeding, yet the author believes that hosts of perfectly 
healthy babies can be reared on cow's milk, if good judgment is applied 
in the selection of suitable milk mixtures. A mixed diet is advocated for 
infants over nine months of age and well tried formulas and diet lists 
are appended for infants and older children. A special dietary is also 
provided for mentally deficient children. 

The author hopes that the chapter on examination of the patient and 
semeiology of disease will greatly aid especially the beginner to surmount 
the difficulties of diagnosis in infants and older children. The normal 
anatomy and physiology are contrasted with the abnormal. Prominent 
symptoms which several diseases have in common are analyzed in rela- 
tion to their pathogenesis and the different methods of physical diagnosis 
are amply elucidated and illustrated. The article on the clinical signifi- 
cance of the large abdomen may prove of special interest to the reader. 

The time for "snap diagnoses" is past. Every obscure fever can no 
longer be dubbed malaria, and every cold bronchitis, for the very good 
reason that up-to-date laymen are sufficiently educated to demand a 
more exact and scientific diagnosis. To meet this requirement, a careful 
survey is presented of the most modern methods of laboratory diagnosis, 
such as the Schick test, the complement-fixation reaction of tuberculosis, 
the tuberculin tests, the Wassermann reaction of syphilis, the Widal re- 
action of typhoid fever and the Weil-Felix reaction of typhus fever. The 
therapeutic value and the indications for the use of serums and vaccines 

7 



8 PREFACE 

are fully discussed and the prophylactic efficiency of diphtheria-toxin- 
antitoxin-immunization is dwelt upon at length. 

A mere glance at the chapter on materia medica will assure the reader 
that the author is not a therapeutic nihilist, but on the contrary, a firm 
believer in the efficiency of some drugs. One of the principal reasons for 
the survival of many, often utterly useless, proprietaries is the fact that 
medical students receive but perfunctory instruction in pharmacology 
and prescription writing, and often do not even appreciate the inertness 
and incompatibilities of the drugs contained in the concoctions. The 
author hopes that the young beginner will profit by memorizing his ar- 
ticle on select and palatable medication and by making use of some of 
the numerous prescriptions distributed throughout the book. Attention 
is also directed to the. instruction given in hydrotherapy, (which includes 
hypodermoclysis, saline, intravenous, intraperitoneal and intrasinus in- 
jections) massage, electricity, climatology and organotherapy. 

To obviate the great loss of life that still prevails among the newborn, 
their diseases, and more especially those of septic nature, are gone into 
minutely. It has often occurred to the author that a certain number of 
cases of dislocation of the hip in infants instead of being congenital in 
character are in reality acquired as a result of sepsis, and he hopes that 
the reader will henceforth scrutinize these cases with greater care and 
possibly confirm the author's observations. Under the head of "Feeble 
Vitality" are grouped the diverse diseased conditions in which feeble 
vitality forms the predominating feature. Herein are included also the 
premature babies which need the special care chiefly to overcome their 
feeble vitality. 

A separate chapter is also reserved for the numerous congenital mal- 
formations which are frequently amenable to treatment if taken in 
hand early and treated skillfully. This refers especialty to congenital 
pyloric stenosis which is fully discussed from a medical as well as surg- 
ical point of view. A great many illustrations accompany the text and 
should prove helpful early to detect the divers abnormalities. 

In the description of acute gastroenteric affections the classification of 
Finkelstein is followed with but slight modifications. As the great ma- 
jority of these cases are the result of milk infection, stress is put chiefly 
upon the care in handling the milk and the dietetic changes that are 
indicated in individual cases. The active treatment is presented briefly 
and clearly and is based upon the author's personal experience. Faulty 
metabolism is treated in another section of the book, in which are 
grouped rachitis, scorbutus, acidosis, exudative diathesis, glycosuria 
and the allied affections. Intussusception and appendicitis are dis- 
cussed as strictly surgical diseases. 



PREFACE y 

The section on respiratory diseases includes those of the nose, throat, 
and ears. The importance of diseased tonsils and adenoids as the im- 
mediate cause of widespread systemic infections is given due prominence. 
Enucleation of the tonsils is advocated in preference to tonsillotomy, 
which latter generally fails to eradicate the source of the trouble. On 
the other hand, it cannot be denied that tonsillectomy is a rather serious 
operation. All the necessary precautions against untoward results are 
amply emphasized when speaking of the dangers of the operation. The 
diagnosis of deafness is elaborated with greater detail than in other text- 
books on pediatrics ; the different tests will prove useful to the family 
physician who is often consulted about the listlessness and inattentiveness 
of some of his little patients. In the description of the diverse inflam- 
mations of the lungs and pleura, the author has endeavored to embody 
the very latest advances in serology which offer the only hope for the 
ultimate discovery of a specific against pneumonia. Influenza pneu- 
monia is described in connection with influenza. The newest views on 
the etiology of asthma are given due consideration, but the author is 
inclined to the belief that the symptoms arising from protein sensitive- 
ness, anaphylactic manifestations, etc., are entirely distinct from those 
of genuine asthma, and transient in character, irrespective of the thera- 
peutic measures employed. 

With introduction of school inspection in a number of states the fact 
has been disclosed that heart disease in children is by far more common 
than was generally supposed. How much of it may be congenital in 
character is difficult to judge from the reports at hand. In the section 
of heart disease, both the congenital and acquired forms of heart disease 
are fully elucidated. Rest and digitalis are still urged as the only re- 
liable therapeutic means at our command in heart disease, more espe- 
cially in the noncompensating variety. Unfortunately few children can 
accommodate themselves to a regime of everlasting rest. The benefits 
derived from graduated exercises in heart disease of children which are 
fully delineated in this chapter are as yet an unknown quantity, yet 
worthy of trial. The author has failed to find any signal diagnostic help 
from the use of the sphygmomanometer, sphygmo graph, cardiograph, 
and similar apparatus, hence has omitted their description. 

Except for the recent advances in the study of blood coagulation prac- 
tically no progress has been made in the knowledge of the diverse blood 
affection. No attempt therefore has been made to disrupt the generally 
accepted classification and methods of treatment. For the want of a 
better term hemorrhea is used instead of hemophilia — which latter is an 
utterly inappropriate designation for spontaneous hemorrhage. Trans- 
fusion is recommended as the most reliable remedy to control this kind 



10 PREFACE 

of bleeding. The author has refrained from going into a minute de- 
scription of the pathology of blood diseases, since excepting Von 
Jaksch's anemia, which is peculiar to childhood, they are fully discussed 
in text-books on general medicine. 

To a great extent the same holds true of kidney diseases, except pye- 
litis, which is of very frequent occurrence in children, and hence is re- 
ceiving careful attention. A great deal is yet to be learned about the 
management of pyelitis. Like the urinary antiseptics the use of vac- 
cines and kidney flushing have thus far failed in the majority of recal- 
citrant cases. The importance of early diagnosis and prompt treatment 
of cervicitis and vulvovaginitis is strongly emphasized and should re- 
ceive due consideration on the part of the general practitioner who has 
ample opportunities to observe them. 

The rather frequent association of acidosis with pyelitis is deserv- 
ing of consideration from an etiologic, as well as therapeutic, point of 
view. 

In recent years the profession has learned to appreciate the vital role 
the ductless glands are playing in the human economy, and the need 
for further scientific investigation. This subject therefore is treated 
broadly, laying particular stress upon the diseases of the thyroid, 
thymus and pituitary glands. The correlation of the disturbed functions 
of these glands to mental deficiencies is emphasized in another section 
of the book, when discussing the mental affections of infants and older 
children. A separate chapter is devoted to this greatly neglected subject. 
The diseases of the lymphatics, the skin and bones are dwelt upon at 
length. Attention may here be directed to the article on malignant 
disease in children which is often overlooked in the early stages. Several 
vivid photographs and roentgenograms illuminate the text. 

The author hopes that the chapter on nervous diseases will be found 
especially instructive. The brain and cord have ceased to be organs best 
let alone, and the progressive surgeon does not at all hesitate to operate 
on the brain as occasions arise. Emphasis is put upon the advisability 
of operating upon suitable cases of cerebral hemorrhage in the newborn, 
spastic cerebral paralysis, epilepsy, etc. Spasmophilia and hysteria are 
elaborated with great care. In order to facilitate their study in con- 
nection with diseases of the brain as a whole, meningitis, poliomyelitis 
and encephalitis are incorporated in this chapter, although from an 
etiologic point of view they belong in the section of contagious diseases. 
Of the greatest importance, of course, to the general practitioner is a 
thorough acquaintance with the communicable diseases of childhood 
which are ever rampant and creating an overabundance of misery to man- 
kind. This subject is treated exhaustively, and includes a large number 



PREFACE 11 

of tropical diseases which have recently invaded our shores. A special 
article is allotted to pertussis in the newborn infant. Epidemic in- 
fluenza in all its phases is described in detail, more especially its patho- 
genesis and serum treatment. The same applies to poliomyelitis already 
spoken of which is clarified by a large number of original illustrations. 
The exanthemata are discussed from a modern point of view. In the 
article on tuberculosis are included the tuberculous affections of the 
brain, glands, skin and bones. Syphilis, in all its forms, is receiving ex- 
plicit consideration. As already stated, the diphtheria-toxin-antitoxin- 
immunization and the diverse laboratory diagnostic tests are discussed 
in the chapter on the prevention and control of disease. 

In closing the author wishes to extend his gratitude to the authors and 
publishers whose literature and illustrations have aided him in the 
preparation of the book; and he is particularly grateful to his pub- 
lishers for their liberal suggestions and good will. 

H. B. S. 

New York City. 



CONTENTS 



CHAPTEE I 



Prevention and Control of Disease 25 

Inherent Strength, 25 ; Power of Resistance and Susceptibility, 26 ; Nutri- 
tion, 26; The Digestibility of the Proteins of Milk and Their Role in 
Infant Nutrition, 26; Physiology and Pathology of the Digestion of the 
Carbohydrates in Infancy, 32; Fat Metabolism, 37; Fat Retention and 
Excretion in Relation to Diet, 38 ; Fat in the Stools of Breast Fed In- 
fants, 38 ; Fat in the Stools of Infants Fed on Modifications of Cow 's 
Milk, 39 ; Fat in the Stools of Children on a Mixed Diet, 39 ; The Diges- 
tion of Some Vegetable Fats by Children on a Mixed Diet, 41; Woman's 
Milk Feeding, 42 ; Artificial Feeding, 48 ; Cow 's Milk Feeding; 48 ; Labo- 
ratory and Home Modification of Cow's Milk, 51; Indications of Faulty 
Assimilation of the Food, 55; Cow's Milk Substitutes, 56; Weaning the 
Baby and Its Feeding Thereafter, 59 ; Hygiene and Sanitation, 64 ; Gen- 
eral Care of the Newborn and Older Children, 64; Immunization — 
Acquired Immunity. Biologic Diagnosis and Therapeutics, 71 ; Variola 
Vaccine, 72; Vaccination, 72; Antidiphtheritic Serum, 75; Diphtheria 
Toxin- Antitoxin Immunization, 75 ; The Local and Constitutional Reaction, 
76 ; The Immunization Response in Susceptible Children, 76 ; The Immuniz- 
ing Results, 76; Antitetanic Serum, 77; Antimeningitis Serum (Flexner), 
78 ; Bacterial Vaccines, 81 ; Tuberculin Tests and Tuberculins, 82 ; Comple- 
ment-Fixation Reaction in Tuberculosis, 84; Serum Diagnosis of Syphilis 
(Wasserniann), 85; Serum Diagnosis of Typhoid, 86; Weil-Felix Reaction 
of Typhus Fever, 87; Allergy or Food Idiosyncrasy-Test, 87; Materia 
Medica and Therapeutics, 88; Hydrotherapy, 88; The Internal Use of 
Water, 92; Electricity, 96; Massage, 99; Climatotherapy, 100; Select 
Medication in Children, 101; Digestants, 103; Tonics, 103; Mineral Acids, 
105; Alteratives, 105; Antipyretics and Antirheumatics, 106; Hypnotics, 
Anodynes and Antispasmodics, 107; Stimulants, 108; Heart Sedatives, 
109; Emetics, 109; Expectorants, 110; Diuretics and Diaphoretics, 110; 
Laxatives and Purgatives, 111; Intestinal Astringents, 112; Gastric Seda- 
tives, 112; Organotherapy, 113; Vitamines, 114. 

CHAPTER II 

Examination of the Patient and Semeiology of Disease 115 

The Head, 116; The Face, 118; The Eyes, 120: The Ears, 122; The Nose, 
122; The Lips, 123; The Oral Cavity, 123; The Neck, 129; The Thorax, 
and its Contents, 129; Auscultation and Percussion, 129; The Thorax, 
132; The Lungs, 133; Cough, 138; Sputum, Expectoration, 138; The 
Heart, 139; The Abdomen and Its Contents, 146; The Diagnostic Sig- 

12 



CONTENTS 13 

nificance of Chronic Abdominal Enlargement, 151; Infants' Stools, 158; 
Principal Abnormalities of Urine, 159; The Genitalia, 164; The Rectum, 
165; The Vertebral Column, 165; The Extremities, 166; Weight and 
Length of Normal Children, 171. 

CHAPTER III 

Congenital Malformations 174 

Congenital Malformations of the Head, 174; Cephalocele (Hernia of the 
Brain), Meningocele, Encephaloeele, Encephalocystocele or Hydroceph- 
alocele, 174; Congenital Malformations of the Face, Including those of 
the Palate, Mouth, Eyes, Nose and Ears, 175; Clefts of the Face and Lips, 
175; Cleft Palate (Palatum Fissum, Palatoschisis), 176; Defects of the 
Mouth and Tongue, 177; Malformations of the Eyes, 177; Malformations 
of the Nose, 179; Malformations of the Ears, 179; Malformations of 
Larynx and Trachea, 180 ; Malformations of the Neck, 180 ; Malformations 
of the Thorax, 182; Malformations of the Alimentary Tract, 183; Con- 
genital Stenoses and Atresia? of the Intestines, 183; Congenital Hyper- 
trophy and Dilatation of the Colon (Megacolon Congenitum, Hirschsprung's 
Disease), 184; Atresia of the Rectum and Anus, 186; Defects of the Ab- 
dominal Parietes, 187; Congenital Umbilical Hernia, 188; Persistence of 
the Ductus Omphalomesentericus, 190; Urachus' Fistula, 191; Malforma- 
tions of the Genitourinary Organs, Congenital Abnormalities of the Kid- 
neys, 192 ; Malformations of the Ureters, 192 ; Malformations of the Blad- 
der, 192 ; Malformations of the Urethra, Prepuce, Testicles, and Vagina, 
193 ; Congenital Phimosis, 193 ; Cryptorchidism, 195 ; Hydrocele, 195 ; Con- 
genital Malformations of the Vertebral Column, 197; Spina Bifida or 
Hernia of the Cord, 197; Congenital Sacral Tumors, 200; Malformations 
of the Extremities and Hip, 201 ; Luxatio CoxaB Congenita, 201 ; Talipes, 
202; Congenital Affections of the Muscles and Bones, 204; Amyatonia 
Congenita, 204; Myotonia Congenita, 205; Osteogenesis Imperfecta, 205. 

CHAPTER IV 

Injuries and Diseases of the Newborn 207 

Birth Injuries, 207; Superficial Structures, 207; Caput Succedaneum, 207; 
Cephalhematoma, 207; Hematoma Sternocleidomastoidei, 208; Deep Struc- 
tures, 208; Central Birth Paralysis, 208; Cerebral Hemorrhage Apoplexia 
Neonatorum, 208; Peripheral Birth Paralysis, 210; Facial Palsy, 210; 
Brachial Paralysis — Obstetrical Paralysis — Duchenne-Erb Paralysis, 211; 
Diseases of the Newborn, 213; Feeble Vitality of the Newborn, 213; 
Asphyxia Neonatorum, 213; Atelectasis Neonatorum, 213; Vitia Cordis, 
214; Syphilis Embryonalis s. Fetalis, 214; Premature Birth, 214; Man- 
agement of "Feeble Vitality of the Newborn" with Special Reference 
to the Premature Baby, 216; Sclerema Neonatorum, 218; Scleredema 
Neonatorum, 218; Sepsis Neonatorum, 219; Local Sepsis, 219; Omphalitis 
(Inflammation of the Navel), 219; Omphalorrhagia (Bleeding from the 
Navel — Idiopathic Umbilical Hemorrhage), 222; Umbilical Granuloma 
(Excrescence, Fungus, Sarcomphalos, 222; Ophthalmoblennorrhea Neo- 



14 CONTENTS 

natorum (Gonorrheal or Purulent Ophthalmia, 222; Pemphigus Neona- 
torum, 224; Dermatitis Exfoliativa Neonatorum, 225; General Sepsis, 
226; Tetanus (Trismus) Neonatorum, 226; Arteritis and Phlebitis Um- 
bilicalis, 228; Erysipelas Neonatorum, 229; Helena Neonatorum, 229; 
Epidemic Hemoglobinuria with Icterus in the Newborn, 229; Acute Fatty 
Degeneration of the Newborn (Buhl's Disease), 230; Functional Dis- 
orders of the Newborn, 231; Uric Acid Infarct, 231; Icterus Neonatorum 
Catarrhalis, 231; Mastitis Neonatorum, 232. 

CHAPTER V 

Diseases of the Alimentary Tract 233 

Diseases of the Mouth, 233; Stomatitis, 233; Dentitio Difficilis, 236; Dis- 
eases of the Salivary Glands, 237; Salivation, 237; Ranula, 237; Second- 
ary Parotitis, 238; Diseases of the Tongue, 238; Glossitis, 238; Diseases 
of the Esophagus, 239; Esophagitis, 239; Diseases of the Stomach and 
Intestines, 211 ; General Etiology, 211 ; Stenosis Pylori Congenita, 212 ; 
Acute Gastroenteritis, 248; Classification, 218; Cholera Infantum, 250; 
Subacute and Chronic Gastroenterocolitis, 253 ; Dysentery, Enterocolitis, 
Ileocolitis, 257; Acidosis, 257; Proctitis, 257; Colica Infantum, Gastralgia, 
Enteralgia, Neuralgia Enterica, 257; Chronic Constipation, 259; Prolapsus 
Ani, Prolapsus Recti, 263; Intussusception, 261; Appendicitis, Typhlitis, 
Perityphlitis, 269; Peritonitis Acuta, 275; Intestinal Worms, 276; Anky- 
lostomiasis, Uncinariasis, 280 ; Diseases of the Liver, 283 ; Icterus Ca- 
tarrhalis, 283; Diseases of the Parenchyma of the Liver, 283; Cirrhosis 
of the Liver, 281; Acute Yellow Atrophy, 285; Fatty Liver, 285; Amy- 
loid Liver, 285 ; Abscess of the Liver, 285 ; Tumors of the Liver, 286. 

CHAPTER XI 

Diseases of the Respiratory System 287 

General Remarks, 287; Diseases of the Nose and Throat and Ear, 288; 
Rhinitis Acuta, 288; Rhinitis Chronica, 289; Epistaxis, 289; Tumors and 
Foreign Bodies in the Nose, 290 ; Sinusitis, 291 ; Pharyngitis Acuta, 292 ; 
Pharyngitis Chronica, 292; Angina, 293; Tonsillitis Acuta, Amygdalitis, 
Quinsy, 293; Hypertrophy of the Tonsils, 296; Adenoid Vegetations, 
297; Dangers and Accidents Attending Adenoid and Tonsil Operations, 
300; Retropharyngeal Abscess, 301; Otitis Media, 303; Deafness, 306; 
Interpretation of Tests for Hearing, 307; Indications of Labyrinth or 
Auditory Nerve Deafness, 308; Laryngitis Acuta, 308; Laryngitis Chronica, 
311; Edema Glottidis, 313; Laryngeal Tumors, 313; Foreign Bodies in the 
Larynx, 314; Diseases of the Bronchial Tubes, Lungs and Pleura, 311; 
Bronchitis Acuta, 314 ; Bronchitis Chronica, 316 ; Broncho or Lobular Pneu- 
monia, 316; Lobar Pneumonia, 320; Pleuritis, 327; Dry Pleurisy, 327; 
Pleurisy with Effusion, 328 ; Serous or Serofibrinous Pleurisy, 330 ; Hemor- 
rhagic and Tuberculous Pleurisies, 330; Purulent Pleurisy (Empyema, 
Pyothorax), 331; Chylous Pleuritis (Chylothorax), 333; Asthma, 337; 
Emphysema Pulmonum, 339 ; Bronchiectasis, 310 ; Pulmonary Gangrene, 
341; Pneumothorax, Hemopneumothorax, Pyopneumothorax, 343; Pneu- 
niohypoderma, 344. 



CONTENTS 15 



CHAPTER VII 



Specific Communicable Disease 345 

Influenza, 345; Vaccine from Influenza Bacillus as a Prophylactic, 354; 
Vaccines from Streptococcus and Other Organisms, 356; The Polyvalent 
Vaccine of Rosenow, 357; Rubeola, 358; Rubella, 363; Diphtheria, 365; 
Differential Diagnosis, 374; Intubation in Laryngeal Diphtheria, 376; 
Tracheotomy, 381; Scarlatina, 382; The Fourth Disease, 394; Varicella, 
394; Variola Vera. Varioloid, 395; Typhus Abdominalis, 399; Typhus 
Exanthematicus, 404; Typhus Recurrens, 404; Glandular Fever, 405; Ma- 
laria, 405; Intermittent Fever, 406; Remittent (Estivo-autumnal) Fever, 
407; Chronic Malarial Cachexia, 408; Dengue, 410; Rocky Mountain Fever, 
410 ; Pestis Americana, 411 ; Ileocolitis Epidemica, 412 ; Rheumatismus 
Acutus, 414; Differential Diagnosis, 418; Rheumatoid Arthritis, 420; 
Still's Disease, 422; Rheumatisms Nodosus Infantilis, 422; Erythema 
Nodosum, 424; Peliosis (Purpura) Rheumatica, 424; Myositis, 425; 
Polymyositis, 425 ; Myositis, Ossificans, 426 ; Multiple Exostoses, 
426; Meningitis Cerebrospinalis, 427; Poliomyelitis Anterior, 427; En- 
cephalitis Lethargica, 427; Parotitis Epidemica, 427; Pertussis, 429; 
Whooping Cough in the Newborn, 434; Tuberculosis, 437; Introductory 
Remarks, 437 ; Miliary Tuberculosis, 442 ; Phthisis Pulmonum, 444 ; Tuber- 
culosis of the Brain, 452 ; Tuberculosis of the ' Abdominal Organs, 453 ; 
Tuberculous Peritonitis, 453; Intestinal Tuberculosis, 456; Tuberculosis 
of the Genitourinary Tract, 456 ; Serof ulosis, 458 ; Tuberculosis of the 
Bones and Joints, 461 ; Tubercular Osteomyelitis and Arthritis, 461 ; 
Tuberculosis of the Vertebral Column, 462; Morbus Coxarius, 466; Knee- 
Joint Disease, 470; Spina Ventosa, 472; Nontuberculous Osteomyelitis, 
473; Osteosarcoma, 476; Scoliosis, 479; Syphilis Hereditaria s. Congenita, 
482; Syphilis Embryonalis, s. Fetalis, 482; Syphilis Neonatorum, 483; 
Syphilis Hereditaria Tarda s. Lata, 490; Acquired Syphilis, 494; Frani- 
besia, 496; Leprosy, 497; Pestis Bubonica, 499. 

CHAPTER VIII 

Disturbances of Metabolism 501 

Marasmus, Athrepsia, Infantile Atrophy, 501; Rachitis, 503; Achondro- 
plasia, 512; Scorbutus Infantum, 514; Beriberi, 517; Pellagra, 517; Dia- 
betes Mellitus, 518; Diabetes Insipidus, 520; Adipositas, 520; Exudative 
Diathesis, 521; Acidosis, 522. 

CHAPTER IN 

Diseases of the CirculatopvY System 525 

Congenital Heart Disease, 525; Persistence of the Foramen Ovale, 526; 
Persistence of the Ductus Arteriosus Botalli, 526; Defects in the Septum 
Ventriculorum, 527; Congenital Stenosis of the Pulmonary Artery, 527; 
Congenital Stenosis of the Tricuspid Valve, 528 ; Congenital Stenosis of 
the Ostium Atrioventriculare Sinistrum, 528; Dextrocardia, 529; Acquired 
Heart Disease, 529; Myocarditis, 529; Pericarditis, 530; Endocarditis 



16 CONTENTS 

Acuta, 533; Endocarditis Chronica, 536; Differential Diagnosis, 539; 
Stage of Compensation, 540; Formal Gymnastics — Cardiac Cases, 542; 
State of Failing Compensation, 544. 

CHAPTER X 

Diseases of the Blood and Ductless Glands 546 

Diseases of the Blood, 546; Anemia Simplex/ Chlorosis, 547; Pseudoleu- 
kemia Infantum, Splenica, 549; Pseudoleukemia Lymphatiea, 550; Leu- 
kemia, 550; Pernicious Anemia, 551; Hemorrhea Congenita, 552; Hemor- 
rhea Acquista, 553; Differential Diagnosis, 555; Morbus Addisonii, 556; 
Diseases of the Spleen, 556; Movable Spleen, 556; Acute Splenitis, 557; 
Chronic Inflammation of the Spleen, 557; Banti's Disease, 557; Primary 
Family Splenomegaly (Gaucher), 558; Adenitis and Lymphadenitis, 559; 
Diseases of the Thyroid Gland, 561; Thyroiditis, 561; Goiter, 561; Ex- 
ophthalmic Goiter, 563; Cretinism, 563; Diseases of the Thymus Gland, 
564; Acute Thymitis, 566; Chronic Thymitis, 567; Disease of the Pitui- 
tary Gland, or Hypophysis Cerebri, 571 

CHAPTEE XI 

Diseases of the Kidneys, Bladder, etc 572 

Nephritis Acuta, 572; Nephritis Chronica, 577; Nephrolithiasis, 578; 
Pyelitis, Pyelonephritis, Pyelonephrosis, 580; Hemoglobinuria, 581; Or- 
thotic, Lordotic, Cyclic or Functional Albuminuria, 582 ; Tumors of the 
Kidney, 582; Cystitis, Colicystitis, 584; Vesical Calculi, 586; Spasmus 
Vesicae, Dysuria, Ischuria, 586; Enuresis, 587; Vulvovaginitis, 589; Mas- 
turbation, 593; Menstruatio Precox, 594; Gangrene of the Genitalia, -594. 

CHAPTEE XII 

Diseases of the Nerve System . . 596 

Organic Diseases, 596; Hydrocephalus, Congenital and Acquired, 596; 
Anemia of the Brain, 600; Hyperemia of the Brain, 601; General Eemarks 
on Cerebral or Central Paralysis and Brain Localization, 601 ; Intracranial 
Hemorrhage, 603; Embolism of the Brain Arteries, 604; Sinus Throm- 
bosis, 604; Meningitis Acuta, 605; Meningitis Cerebrospinalis, 605; Men- 
ingococcic, Pneumococcic, Tuberculous, Streptococcic, etc., Meningitis, 
605 ; Differential Diagnosis, 613 ; Diplegia Spastica Infantilis, 615 ; Hemi- 
plegia Spastica Infantilis, 618; Encephalitis, 620; Brain Abscess, 621; 
Lethargic or Epidemic Encephalitis, 624; Poliomyelitis Anterior, 627; 
Tumors of the Brain, 645 ; Epilepsia, 649 ; Migraine, Hemicrania, 653 ; 
Pavor Nocturnus, 654 ; Syringomyelia, 654 ; Spinal Hemorrhage, 655 ; 
Spinal Meningitis, 655; Myelitis, 656; Ataxia Hereditaria (Friedreich), 
Heredoatoxie Cerebelleuse (Marie), 657; Disseminated Sclerosis, 657; 
Hereditary Progressive Muscular Atrophies, 658; Spinal Progressive Mus- 
cular Atrophy, 658; Neural Progressive Muscular Atrophy, 658; Myo- 
genic Progressive Muscular Atrophy, 659 ; Lipodystrophia Progressiva, 
661; Tumors of the Cord and Membranes, 662; Peripheral Facial Paral- 



CONTENTS 17 

ysis, 663; Hemiatrophia Faciei, 665; Polyneuritis, 665; Functional Dis- 
eases, 668; Spasmophilia, 668; Eclampsia Infantum, 669; Tetanism, 671; 
Tetany, 673; Pseudotetanus (Eschericli), 676; Spasmus Glottidis, 677; 
Chorea Vera, 678; Habit Spasm, 681; Spasmus Nutans, 682; Hysteria, 
682; Dystonia Musculorum Deformans, 688. 

CHAPTER XIII 

Amentia 690 

Idiocy and the Allied Mental Deficiencies, 690 ; In Infancy and Child- 
hood, 690; Stigmata of Degeneration, 697; Normal Intelligence, 698; 
The Abnormal Baby, 701 ; Mental Tests, 705 ; Classification, 706 ; Micro- 
cephalus, 707; Hydrocephalus, 710; Paralytic Amentia, 712; Amaurotic 
Family Idiocy, 716; Mongolism, 718; Cretinism, Myxidiocy, 721; Infan- 
tilism, 726; Moramentia, 728; Prophylaxis, 732; Active Treatment, 737; 
Hygiene, 737; "Incentive" Training and Physical Therapeutic Measures, 
739 ; Medicinal Treatment, 746 ; Surgical Treatment, 719 ; Prognosis, 750 ; 
Amentia in Older Children, 751 ; Epileptic Idiocy, 751 ; Imbecility, 752 ; 
Mental Affections in Older Children, 757; Dementia, 757; Dementia Pre- 
cox, Katatonia, Hebephrenia, 757 ; Dementia Paralytica, 759 ; Melancholia, 
759; Mania, 759. 

CHAPTER XIV 

Diseases of the Skin 761 

Eczema, 761; Urticaria, 764; Intertrigo, 765; Psoriasis, 766; Herpes zos- 
ter, 767; Miliaria, Lichen Strophulus, 768; Ecthyma, 768; Impetigo Con- 
tagiosa, 769; Pediculosis Capitis, 770; Pediculosis Corporis, 771; Pedicu- 
losis Pubis, 771; Scabies, 771; Tinea Trichophytina Capitis, 774; Tinea 
Trichophytina Corporis, 776; Molluscum Contagiosum, 776; Telangiectases, 
Xevi and Angiomas, 777; Combustio, 778; Congela.tio, 779. 



COLOR PLATES 



PLATE PAGE 

I. The normal stool of the breast-fed infant 42 

II. Formed alkaline stools . 54 

III. Stomatitis aphthosa (advanced stage) 234 

IV. The green, acid stool of dyspepsia 250 

V. Angina follicularis. Angina herpetiformis, after vesicles burst. Angina 

ulcerosa (Vineentii) 292 

VI. Buccal exanthema in measles (Koplik's spots) 360 

VII. Tonsillar diphtheria 366 

VIII. Angina scarlatinosa and "strawberry tongue" 384 

IX. Life-cycle of Plasmodium vivax 406 



ILLUSTRATIONS 



FIG. PAGE 

1. Microscopic appearances of woman's milk 42 

2. Breast pumps 44 

3. Holt 's milk testing apparatus 45 

4. Chapin's dipper for removal of " top-milk " 50 

5. Stages in Widal reaction of typhoid. 86 

6. Hydrocephalus 117 

7. Fontanels 118 

8. Diagram of the visual tract 121 

9. Temporary and permanent teeth 125 

10. Ulcerative stomatitis involving also the lips and adjacent structures . . . 127 

11. The thoracic and abdominal regions 130 

12. The regions of the back 131 

13. Diagnostic lines of the thorax 135 

14. Anterior boundaries of the lungs 135 

15. Posterior boundaries of the lungs 135 

16. Normal heart of a child three years old 140 

17. Normal heart of a child eight years old 141 

18. The relative and absolute heart dulness up to four years 142 

19. The relative and absolute heart dulness up to eight years 142 

20. The relative and absolute heart dulness up to twelve years ...... 142 

21. Topography of cardiac valves 144 

22. The thoracic and abdominal regions 146 

23. Dissection of still-born child 148 

24. Topography of the liver and spleen 149 

25. Topography of kidneys, spleen, and liver ............ 150 

26. Sarcoma of the left kidney 153 

27. High degree of rachitis. Abdominal enlargement chiefly in epigastric region 154 

28. Tuberculous peritonitis. Abdominal enlargement most marked in hypo- 

gastric region 155 

29. Buffalo scale 172 

30. Normal infant's weight chart 172 

31. Harelip 176 

32. Bilateral congenital anophthalmia 178 

33. Large asymmetrical cervical ribs; neuritis and vascular disturbances in the 

right arm 182 

34. Moderate degree of megacolon congenitum or Hirschsprung's disease, in a 

child three years old 184 

35. Congenital absence of anus and rectum and of scrotum and its contents . 1S5 

36. Stomach and intestines of case shown in Fig. 35, showing ending of colon 

in a blind pouch filled with meconium 186 

37. Diastasis recti abdominis in an amaurotic idiot 187 

18 



ILLUSTRATIONS 19 

FIG. PAGE 

38. Congenital umbilical hernia 188 

39. Congenital femoral hernia 189 

40. Ectopia viscerivm 189 

41. Thoracoabdominopagus with prolapse of intestines 189 

42. Skiagram of thoracoabdominopagus. (Same as Fig. 41.) 190 

43. Congenital hydrocele communicans : 196 

44. Myelocystocele 198 

45. Spina bifida occulta in a boy eight years old. This condition was associated 

with incontinence of urine 199 

46. Bilateral club feet in father and three children 202 

47. Same case as Fig. 44 showing also congenital club foot 203 

48. Osteogenesis Imperfecta . 205 

49. Method of insertion of trocar through the anterior fontanel to reach the 

ventricles 209 

50. Obstetric facial paralysis in boy fifteen months old, which failed to yield 

to treatment 210 

51. Bilateral obstetric brachial paralysis, the so-called " Duchenne-Erb Par- 

alysis" 211 

52. Obstetric brachial palsy: Erb's "upper arm type;" failed to respond to 

treatment 212 

53 Incubator room for newly born babies with feeble vitality . „ . . . . 216 

54. Breck's feeder 217 

55. Absorption of left head of femur and consequent dislocation of the hip in 

a child two years old as a direct result of sepsis neonatorum which be- 
gan with an infection in the navel 220 

56. High degree of "tetanism" greatly resembling tetanus neonatorum. Note 

Fig. 59, showing same case during partial relaxation of the spasm . 227 

57. Penny in esophagus of an infant readily extracted under the guidance of 

the roentgen ray 239 

58. Pylorus stenosis in a boy three months old 243 

59. Chronic gastroenteritis in an infant ten weeks old 254 

60. Prolapsus recti 263 

61. Stick pin in transverse colon giving rise to symptoms of intussusception 

requiring operation 266 

62. Oxyuris vermicularis. Female and male 277 

63. Ascaris lumbricoides 277 

64. Tenia saginata 277 

.65. Tenia solium 278 

66. Bothriocephalus latus 278 

67. Ankylostomum duodenale 281 

68. Uncinaria Americana 281 

69. Toy ring in antral cavity giving rise to empyema of the antrum of High- 

more in a child three years old 291 

70. Adenoids in a boy eleven years old. Note characteristic dull, facial features 

and contracted chest 297 

71. Spinal curvature (stooping) secondary to adenoids 298 



20 ILLUSTRATIONS 



FIG. PAGE 

72. Retropharyngeal abscess in a ten-month-old infant. Note characteristic 

attitude of mouth, head and neck 302 

7.*>. Fever curve of typical lobar pneumonia in a child fourteen months old, end- 
ing- by crisis 322 

74. Fever curve of a fatal case of apex pneumonia with marked cerebral symp- 

toms in a child two years old 322 

75. Grocco's sign of pleurisy with effusion (paravertebral triangle of dulness 

on the side opposite to that of the effusion — G) 329 

76. Extensive right empyema in a child four years old 332 

77. Same case as Fig. 76 three weeks after resection of second and third ribs. 

Note clearing of right lung 335 

78. Same case as Fig. 76 two months later. Eight lung field almost clear. 

Note retraction of chest wall and secondary scoliosis 336 

79. Pneumothorax (posterior view). Note compression of lungs and disloca- 

tion of heart 341 

80. Pneumohypoderma (emphysema, cutis) in a girl five years old complicating 

measles with pneumonia 342 

81. Same case as Fig. 80 six weeks later 343 

82. Section of lung of epidemic influenza in a young infant showing congestion 

of the blood vessels in the pleura and hemorrhages just beneath the 
pleural surface 346 

83. Section of lung of epidemic influenza in a young infant showing suppurative 

bronchitis and areas of pneumonia about the bronchi 348 

84. Fever curve of atypical influenza in a baby fourteen months old . . . 350 

85. Paralysis of N. abducens, with convergent strabismus and facial paralysis 

following postinfluenzal encephalitis. Her mentality remained greatly 

affected 351 

86. Fever curve of measles . 359 

87. Fever curve of German measles 363 

88. Instruments for intubation 378 

89. Mode of feeding after intubation 379 

90. Tracheotomy tube 382 

91. Fever curve of a case of scarlet fever 385 

92. Fever curve of typhoid fever in child four years old 400 

93. Eheumatic torticollis of several weeks' duration in a child six years old 

which greatly resembled cervical spondylitis 417 

94. Still's disease in a boy five years old, showing the arthritis being multiple . 423 

95. Still's disease in a boy five years old. Periarticular changes in the left 

wrist joint 423 

96. Still 's disease in a. boy five years old. Symmetrical changes in the periartic- 

ular soft parts of the knees and ankles 423 

97. Multiple exostoses 427 

98. Epidemic mumps 428 

99-103. Breathing exercise 439 

104. Acute pulmonary miliary tuberculosis (cut surface of the lung) . . . 442 

105. Miliary tuberculosis of the lungs in a child nine years old 443 



ILLUSTRATIONS 21 

FIG. PAGE 

106. Tuberculosis. Horizontal section through the tuberculous lower lobe of 

the right lung of a two-year-old child 445 

107. Phthisis pulmonum in a child twenty months old 447 

108. A group of tuberculous patients in the outdoor " Shack" of the Hospital 

for Crippled and Deformed Children, New York 450 

109. Tuberculosis of the brain (boy four years old) . 452 

110. Tuberculous peritonitis in a baby fifteen months old; she has fully re- 

covered after laparotomy 454 

111. Characteristic early tubercular infiltration of bladder, as seen through the 

cystoscope 457 

112. A large tubercular ulcer below the orifice of the right ureter 457 

113. Cystoscopic view of the base of the bladder in a case of tuberculosis of 

the left kidney 457 

114. Tuberculous axillary lymphadenitis 459 

115. Tuberculosis of elbow joint in a boy eighteen months old. Note discharg- 

ing sinus 461 

116. Pott's disease 463 

117. Eigidity of neck associated with "cervical ribs" 464 

118. Same case as in Fig. 117 showing peculiar attitude of head which led 

to the erroneous diagnosis 464 

119. Advanced dorsal spondylitis with gibbus 465 

120. Tuberculous coxitis, advanced stage 467 

121. Early stage of hip- joint disease . 468 

122. Hip-joint disease 469 

123. Tuberculosis of the knee in a thirteen-month-old infant who a few months 

later succumbed to tuberculous pyothorax 471 

124. Spina ventosa 473 

125. Osteosarcoma of the head and upper third of shaft of humerus in a boy 

ten years old 476 

126. Enchondroma of upper third of humerus in a child eleven years old . . 477 

127. Bone cyst in shaft of humerus causing fracture in a child six years old . 478 

128. Sarcoma of the left femur in a girl eight years old ... .... 479 

129. Lateral spinal curvature; second degree 480 

130. Lateral spinal curvature, S-shaped scoliosis 481 

131. Congenital syphilis, baby three weeks old 483 

132. Syphilitic pemphigus, especially marked on the soles of the feet . . . 484 

133. Congenital syphilis in an eight-week-old baby 485 

134. Congenital syphilis in a six-week-old baby 486 

135. Syphilitic dactylitis of right index finger in a child two years old . . . 487 

136. Periosteal syphilis of left ulna in a child ten years old ....... 488 

137. Syphilitic baby eleven months old 489 

138. Syphilitic " Hutchinson teeth" 491 

139. Gumma of the right parietal bone in an eight-year-old boy suffering from 

syphilis hereditaria tarda 492 

140. Syphilitic osteoperiostitis of the tibiae, "Saber-shape-deformity" and of 

the nasal bones, with high degree of rachitis ......... 493 

141. Case of leprosy in a child showing infiltration especially in ears, lips and 

hands 498 



22 ILLUSTRATIONS 

FIG. PAGE 

142. Marasmus in a child ten months old 502 

143. Rachitic "frons quadrata" in an infant thirteen months old .... 504 

144. Rachitic beading of the ribs, "pot-belly," and bow-legs 505 

145. High degree of rachitic spinal curvature 506 

146. Rachitic bow-legs, "jug" shaped abdomen and separation of epiphyses 

"double-jointed" 507 

147. Rachitic knock-knee in girl six years old 509 

148. Achondroplasia in a ten-month-old baby 512 

149. Achondroplasia 513 

150. Scorbutus in a fifteen-month-old infant 515 

151. Adipositas; child weighs thirty-six pounds at eight months 521 

152. Vitium cordis . . 525 

153. Dextrocardia in a girl six years old. Posterior view 529 

154. Fever curve of malignant endocarditis in a child three years old . . . 534 

155. Intense dilatation of the heart in a two-month-old infant suffering from 

congenital heart disease which was greatly aggravated by an attack 

of whooping cough 537 

156. Splenomegaly in association with von Jaksch anemia 549 

157 and 158. Primary family splenohepatomegaly, Gaucher type, in brother and 

sister 558 

159 and 160. Distribution of the jn-incipal lymphatic glands of the neck and 

trunk 560 

161. Goiter in girl eleven years old 562 

162. Hypothyroidism — Myxidiocy, in a girl sixteen years old 563 

163. Large thymus 564 

164. Precocious child eight years old; began to menstruate when about five 

years old (hyperpituitaria?) 570 

165. Acute nephritis with general anasarca in a four-month-old infant . . . 573 

166. Same case as Fig. 165 three weeks later . 573 

167. Oval calculus in left ureter and one just emerging from lower pole of left 

kidney in a child nine years old 579 

168. Adenosarcoma of right kidney in a boy twenty-seven months old, occupying 

almost the entire abdomen 583 

169. Congenital hydrocephalus 596 

170. Congenital hydrocephalus with spina bifida 597 

171. Same case as Fig. 170 showing distended spina bifida before escape of 

the spinal fluid. 597 

172. Hydrocephalus following meningitis 598 

173. Acquired acute hydrocephalus, following acute gastroenteritis and compli- 

cating rachitis 599 

174. Epidemic cerebrospinal meningitis 607 

175. Lumbar puncture 610 

176. Fever curve of tuberculous meningitis in a child two years old .... 612 

177. Diplegia spastica infantilis in a baby eight months old who sustained cere- 

bral injuries (with hemorrhages) during obstetric delivery .... 616 

178. Little's disease. "Scissors-Gait" or cross-legged progression .... 616 

179. Diplegia spastica infantilis (Little's disease) 617 



ILLUSTRATIONS 23 

FIG. PAGE 

180. Hemiplegia spastica infantilis, by some authors looked upon as a "cere- 

bral" or " encephalitie " type of poliomyelitis with lesions chiefly in 

the motor area of the cerebral cortex 619 

181. Left hemiplegia following acute encephalitis 620 

182. Poliomyelitis "spinal type;" lesion in lumbar enlargement; atrophy and 

right < ' drop-foot " 633 

183. Poliomyelitis "spinal" type; lesion in cervical enlargement; paralysis of 

upper arm as well as right serratus magnus, "angel wing" deformity 

of right scapula, marked muscular atrophy 633 

184. Poliomyelitis "spinal type;" lesion in cervical and dorsal regions; partial 

paralysis of the muscles of the neck, abdomen, and right thigh 

(atrophy) 634 

185. Poliomyelitis "spinal type;" lesion in cervical enlargement; "neck drop" 634 

186. Poliomyelitis affecting the abdominal muscles giving rise to "ballooning" 

of the abdomen 635 

187. Poliomyelitis "bulbospinal type;" lesion in medulla; paralysis of left 

facial nerve, left forearm and left leg 635 

188. Poliomyelitis "pontine" or "cerebral" type; lesions in pons, medulla, 

and spinal cord; paralysis of right facial nerve, left forearm and hand, 

external respiratory, and abdominal muscles and right leg .... 636 

189. Same case as Fig. 188 showing also high degree of scoliosis 637 

190. Secondary passive hydrocephalus in tumor of the brain 645 

191. 192, and 193. Pseudohypertrophic paralysis. Demonstration of rising 

from the floor by ' ' climbing upon himself " 660 

194. Peripheral facial palsy — Bell's palsy 663 

195. Nuclear facial palsy. Eye muscles are unaffected; paralysis limited to 

lower part of face 664 

196. Diphtheritic polyneuritis in a boy four years old 666 

197. Same case as Fig. 196 two weeks later 666 

198. Same case as Fig. 196 six weeks later 667 

199. Tetanism during acme of spasm. Note characteristic position of the ex- 

tremities 671 

200. Tetanism. Same case as Fig. 199 during partial relaxation of spasm . . 671 

201. Same ease as Fig. 199 three months later 672 

202. Tetany in a child eleven months old 674 

203. Pseudotetanus 676 

204. Hysterical phantom tumor of the abdomen 684 

205. Progressive torsion spasm 688 

206. Microcephalitic idiot 702 

207. Amaurotic idiot 702 

208. Microeephalus — miniature brain 707 

209. Microeephalus — brain degeneration 708 

210. Hydrocephalic idiot 710 

211. Paralytic idiot of antenatal origin 714 

212. Paralytic amentia in consequence of cerebral hemorrhage during instru- 

mental delivery 715 

213. Amaurotic family idiocy in baby 14 months old 717 



24 ILLUSTRATIONS 

FIG. PAGE 

214. Macular change (cherry-red discoloration) in amaurotic family idiocy . . 717 

215. Mongolian idiot of 23 months, Calmuck type I . 720 

216. Cretin from birth; total idiot. Note "trident hand'" 722 

217. Normal at one year J . 723 

218. Same case as Fig. 217 pronounced cretin at eight years . . 723 

219. Same case as Fig. 218 four weeks after treatment with thyroid . -J . . 724 

220. Same case as Fig. 218 ten weeks after treatment with thyroid ..,••; . . . 725 

221. Infantilism, Brissaud type, six years old; measures 32 inches in length . 727 

222. Infantilism, typus Lorain, four and one-half years old; measures 32 inches 

in height and weighs 28 pounds, acts like a two-year-old infant . . 727 

223. Wrist of anient 10 years old; wrist of normal child six years old. Note 

greater number of carpi in the latter 728 

224. Moramentia in a two-year-old boy, as a result of marked adenoids with its 

consequences, especially difficult hearing 729 

225. Moramentia, as a result of isolation and faulty environment 731 

226. Feeblemindedness in a boy eight years old following an attack of en- 

cephalitis: he is suffering also from slight left hemiplegia .... 752 

227. Dementia precox in a girl thirteen years old. Note also cystic degeneration 

of the thyroid gland 757 

228. Seborrheic eczema of head and face 761 

229. Psoriasis in a girl seven years old 766 

230. Herpes zoster 767 

231. Impetigo contagiosa of an unusually severe type 769 

232. Pediculosis capitis, showing ova on hairs 770 

233. Animal parasites 772 

234. Sca.bies, in an infant 773 

235. Trichophyton tonsurans — threads and chains of spores x400 . . . .- . 774 

236. Large-spored ectothrix ringworm of scalp 774 

237. Tinea tonsurans 775 

238. Vascular nsevus . 777 



DISEASES OF CHILDREN 



CHAPTER I 

PREVENTION AND CONTROL OF DISEASE 

Nutrition and Infant Feeding. Hygiene and Sanitation. Immuni- 
zation. Therapy 

The warfare between health and disease evolves with the earliest 
inception of life of the organism. The battle is fiercely rampant and 
everlasting*, the victory at best but temporary. Supremacy of health 
over disease fluctuates with the amount of inherent strength of the 
individual, the natural and acquired power of resistance, and the as- 
sistance received through prophylaxis and therapeusis. 

Nature aims to exterminate the weak, and right at birth tests the 
vitality of the infant in a manner most hazardous to its subsistence. 
Thus, accustomed to the ideal domicile of the maternal uterus — pro- 
tected from traumatism and atmospheric vicissitudes, nurtured with- 
out effort and animated without the touches of pain or distress — the 
newborn is suddenly cast upon its own resources into a sphere of 
eternal strife, where every organism, every element, is struggling for 
supremacy, and where the strongest — not invariably the fittest — 
triumphs. 

Inherent Strength 

Inherent strength is essential to active life, to maintenance of per- 
fect health. A powerful constitution will overcome an attack of dis- 
ease that will fell the weak and the frail. A strong organization will 
surmount hardships and rapidly recuperate after protracted illness. 
Inherent strength is not procurable after birth. It is a consummation, 
an inheritance, of ancestral virility and vigor, premarital purity, con- 
jugal devotion, matrimonial chastity, sobriety and ideal hygiene. It 
can be fostered by regulation of marriage, conservative mutual selec- 
tion, prohibition of consanguineous marriages and those encumbered 
by grave disease, habits, alcoholism and drug addictions, or extreme 
poverty. Finally, it can be greatly improved by judicious management 
of pregnancy. 

25 



26 DISEASES OF CHILDREN 

Power of Resistance and Susceptibility- 
Immunity, protection, or power of resistance against disease, and 
to a slighter extent also susceptibility toward disease, may be natural 
or acquired. It varies in different individuals and in the same indi- 
vidual at different periods of life. Natural or congenital immunity is 
aptly exemplified by the comparatively rare occurrence of communi- 
cable diseases in infants under three months of age. Congenital sus- 
ceptibility is demonstrable by the prevalence of certain affections in 
some families or races, e. g., hemophilia, tuberculosis, amaurotic fam- 
ily idiocy and the like. In contrast to inherent vitality, acquired power 
of resistance is vastly influenced during the life of the child. Thus, 
immunity against communicable diseases is often temporarily or per- 
manently conferred, naturally by a previous attack of the same malady 
(e.g., yellow fever, pertussis), and artificially by: I. Suitable nutrition. 
II. Hygiene and sanitation. III. Immunization. IV. Drugs and physi- 
cal therapeutic measures. 

I. NUTRITION 

Suitable nutrition is indispensable to the life and growth of the in- 
dividual and to the maintenance and advancement of his power of 
resistance. The human economy demands for its sustenance a liberal 
supply of proteids (to build up and to reconstruct the tissues), fat 
and carbohydrates (to produce energy and heat), mineral salts (to 
help formation of bones and teeth), and water (to aid the solubility 
of the food elements and the excretion of waste products). An ideal 
food, therefore, must contain these five ingredients in more or less 
definite proportion, must be readily digestible and assimilable, and be 
free from pathogenic bacteria. (See Vitamines, p. 114.) 

The Digestibility of the Proteins of Milk and Their Role in Infant 

Nutrition* 

While in many respects our ideas of infant nutrition and feeding 
have been modified by the clinical and laboratory researches of the 
last ten or fifteen years, probably in no direction has the change of view 
been so marked as that regarding the proteins. It is not many years 
since the difficult digestion of cow's milk protein was looked upon 
as the important, probably the chief cause of our troubles in infant 
feeding, and many were the expedients resorted to, to overcome this 



*In order to avoid repetition, and also to give the student the latest information on the 
subject, we are here abstracting the articles on "The Digestibility of the Proteins" by Dr. 
L. E. Holt, and "The Digestion of the Carbohydrates" by Drs,. J. D. Morse and F. B.Talbot. 



PREVENTION AND CONTROL OF DISEASE 27 

difficulty, such as various forms of diluent, peptonizing, the addition 
of sodium citrate, etc. But we have learned that the symptoms formerly 
ascribed to the proteins depend upon other conditions. The curds in 
stools we know are composed chiefly of fat; most of the colic and flatu- 
lence are due to carbohydrates, and constipation depends much more on 
fat and salts than on casein. All researches upon gastric digestion in 
infants agree that in practically all conditions pepsin is abundantly se- 
creted. The use of such ferments in disturbances of digestion, though 
still wudely resorted to, has no rational basis. 

Modern practice has certainly been in the direction of using much 
higher proportions of protein than were formerly thought wise or safe. 
It is interesting, therefore, to inquire whether this custom is justified 
by our present knowledge of the digestion of protein by the infant ; 
also whether it is advantageous or whether its use is fraught with 
some disadvantages or possible dangers not apparent on the surface. 

Metabolism experiments made at the New York Babies' Hospital and 
in many other places have revealed the fact that under almost all cir- 
cumstances infants possess a remarkable capacity for retaining nitrogen. 
Even in conditions of severe malnutrition, the protein of cow's milk is 
well borne, as shown by a positive nitrogen balance, even though the in- 
fants were losing weight. This capacity on the part of the infant to 
assimilate protein is an indication of how well nature has provided the 
means of replacing protein waste and promoting growth above other 
needs of the organism. 

Clinical evidence of the infant's tolerance of protein is also not 
wanting. When the question is asked, What are the symptoms of pro- 
tein indigestion or intolerance ? we are compelled to reply that at pres- 
ent we cannot mention any definite symptom or group of symptoms 
which we can positively attribute to the proteins, in the sense that we 
can attribute other definite symptoms to the fats and to the carbohy- 
drates. 

Under these circumstances it is pertinent to inquire whether the 
present practice of giving much higher proteins than formerly is one 
to be recommended without reservation; is this safe? is it advanta- 
geous? or is it possibly injurious? 

The protein needs of the body must certainly be provided for; but 
is it desirable to go much beyond this? Many elaborate calculations 
have been made to determine the actual protein needs of the infant. 
We think we are safe in assuming that they are supplied in woman's 
milk in sufficient amount, but in no considerable excess. The most re- 
cent analyses of Courtney and Fales show that during the mature 
period of lactation, i. e., after the first month, the average protein con- 



28 DISEASES OF CHILDREN 

tent of woman's milk is slightly less than 1.25 per cent. An infant 
taking cow's milk, as it is now usually modified, gets very much more 
than this. 

To put it in another wa}^, assuming an average composition of mature 
woman's milk to be 3.5 per cent fat, 7.5 per cent sugar, and 1.25 per 
cent protein, a nursing infant is receiving a little over 7 per cent of his 
calories in the form of protein; an average artificially-fed infant of 
three months, who is taking cow's milk one-half strength with sufficient 
sugar added to bring the carbohydrates up to 6 per cent, is receiving 
over 14 per cent of his calories as protein; while an average infant 
of six months, who is getting two-thirds milk with the same propor- 
tion of sugar, is receiving nearly 17 per cent of his calories in the 
form of protein. This is on the assumption that all the nitrogen in 
woman's milk and in cow's milk is alike available for nutrition, which 
is not quite true. While this is very nearly the case with cow's milk, 
woman's milk is known to contain nitrogen in other forms than protein 
(extractives, urea, etc.), which reduce the available nitrogen by nearly 
one-fifth. So that the discrepancy between the protein content of 
the two milks is even greater than at first appears. 

Eubner has calculated that on the average the food of the infant 
should have 7 per cent of his calories in the form of protein. This we 
have already seen is practically that which is present in woman's milk. 
What then becomes of the excess of protein given in our common feed- 
ing mixtures ? Our own metabolism experiments have shown that with 
high protein feeding there is at first a marked increase in nitrogen re- 
tention, but that this persists only for a short time and that increased 
intake is followed by an increased excretion which is nearly but not 
quite proportional. 

Protein is needed first of all to supply the nitrogenous waste of 
the cells of the body, one of the constant phenomena of life ; secondly 
for growth; and lastly it may supply heat. The waste or "wear-and- 
tear-needs" of the infant, as compared with the needs of the adult, 
are not great. Growth, according to Rubner, is not in proportion to 
the protein intake and cannot be increased above natural limits by 
increasing the protein intake. The excess he believes is simply burned 
in the body in the place of carbohydrate and fat. The inference from 
his observations is that the protein requirements of the infants are 
relatively small and that if taken in excess of this minimal requirement 
the surplus can be used up in the place of other food elements. 

Some experimental evidence has been brought forward which in- 
dicates that we may not continue to increase the protein in the food 
without incurring some risks; that the protein of cow's milk when given 



PREVENTION AND CONTROL OF DISEASE 29 

in considerable excess of the needs of the body may bring about dis- 
turbances of metabolism causing clinical symptoms of importance, even 
of gravity. 

In a series of metabolism observations made four years ago at the 
Babies' Hospital, it was shown that if large amounts of protein of 
cow's milk were given without whey {i.e., without carbohydrates) 
certain definite symptoms regularly followed — prostration, fever and a 
leukocytosis, which symptoms ceased immediately upon resuming the 
ordinary diet. 

Observations in Lusk's laboratory by Howland and also by Murlin 
and Hoobler have shown that an increase in the amount of protein 
given caused an immediate and very marked increase in the general 
metabolism, and also that if fat and carbohydrates were not furnished 
in the food in sufficient amount, the increased metabolism caused an 
actual loss of these substances from the tissues of the body. In Hoob- 
ler 's case there was observed diarrhea and a condition of semistupor. 

Symptoms like those mentioned in the foregoing observations have 
been seen, it is true, only when protein is given very much in excess of 
the amounts commonly employed. The cause of these symptoms is 
not yet understood and while the observations are by no means con- 
clusive, they are strongly suggestive of possible harm which may re- 
sult from very high protein feeding. The increase in the general metab- 
olism from such feeding, and, under certain circumstances, the actual 
withdrawal of fat and carbohydrate from the body, may furnish an 
explanation of why it is so difficult to increase weight if fat and carbo- 
hydrate, but especially the latter, are much reduced. 

Thus far we have considered the protein needs of the infant only 
from a quantitative standpoint, and until quite recent times this has 
been the chief subject of discussion. The only differences between 
proteins have been indicated by that somewhat vague term of "diges- 
tibility." The latest studies of the food proteins indicate that the 
amount of protein given is much less important than the nature of the 
protein furnished. We have learned from Abderhalden that our com- 
mon food proteins are very complex substances, being made up of 
some sixteen or eighteen different amino-acids. 

Osborne and Mendel have for years been carrying on an extensive 
series of feeding experiments upon animals to determine the specific 
value of the different amino-acids in nutrition. They have shown that 
certain amino-acids are indispensable for growth; others are relatively 
unimportant. Thus if gliadin, a wheat protein, be the form of protein 
given to the animal, although the animal may maintain its weight, 
no growth occurs. But if to this, without increasing the total protein, 



30 DISEASES OF CHILDREN 

a small amount of one of the amino-acids known as lysin is added, a 
gain in weight begins immediately and continues as long as lysin is 
administered; but it ceases at once when it is withheld, and begins 
when it is again furnished to the animal. From many such experi- 
ments they have reached the conclusion that lysin is indispensable for 
growth; without it, no matter what amount of protein food is given, 
the most that the animal can do is to maintain itself in equilibrium. 
There are three other amino-acids of great importance— cystin, tryp- 
tophan and glycocoll. It does not seem possible for normal nutrition 
to go on unless lysin, tryptophan and cystin are furnished in the food; 
glycocoll alone, there is good reason for believing, can be produced 
in the body by synthesis. 

Now as to the bearing of this on infant feeding. Animal proteins, 
as a rule, are relatively rich in those amino-acids which we will call 
the essential ones, while many vegetable proteins are very deficient 
in them. But again there is a wide difference in the amino-acid con- 
tent of the different animal proteins. Lactalbumin is the protein 
which contains the essential ones in largest proportion. Casein, how- 
ever, is notably deficient in at least one important one, cystin. Men- 
del says if the supply of casein is limited, the curve of growth is al- 
tered, not for lack of total protein, which may be entirely adequate, 
but for lack only of cystin, for as soon as this is added to the 
food, normal growth at once begins. Growth, therefore, is limited by 
the supply of cystin. The deficiencies of casein are ordinarily made 
good by the amino-acids of lactalbumin. And right here it should 
be remembered, that in woman's milk the amount of lactalbumin is 
twice the casein, while in cow's milk it is only one-sixth the casein. 
It is surely not an accident that woman's milk has relatively twelve 
times as much lactalbumin as has cow's milk. 

"Woman's milk supplies not only the amount of protein needed by 
the infant for the first eight or nine months of life, it furnishes what 
is more important, the essential amino-acids in sufficient quantity. 
There are good reasons for believing that nature has not intended 
cow's milk to nourish even the calf for a; very long period. The 
maximum secretion of cow's milk is reached at the beginning of the 
second month, after which it steadily declines. Moreover, the calf 
at birth usually has eighteen teeth, indicating again his early capacity 
for digesting other food than milk and also his need of it. Now, the 
secretion of woman's milk increases in quantity under normal con- 
ditions up to eight or nine months, and the human infant does not 
get his teeth until seven or eight months — a strong suggestion that 
up to this time other food is unnecessary for normal nutrition. But, 



PREVENTION AND CONTROL OF DISEASE 31 

in the case of infants -who are artificially fed, conditions are different ; 
although the defects of cow's milk have not been wholly understood, 
we have lately seen the great advantage of the earlier use of other ar- 
ticles of diet — fruit juices, beef juice, egg, broth and even fresh veg- 
etables. Thus we have been unconsciously doing what the calf has 
been doing for a very long time — supplying the deficiencies of cow's 
milk. 

Returning to the subject of casein, Osborne and Mendel have found 
that the gain in weight with 9 per cent of the food solids in the form 
of casein was very low unless cystin was added, but if the casein 
was doubled or increased to 18 per cent, a normal rise in weight was 
seen. "We have here, we believe, a important fact which sheds light 
on some of our failures and successes in infant feeding. We once 
thought that we were supplying the infant's protein needs when we 
gave as much protein in cow's milk as the protein in woman's milk. 
Evidently we were wrong. It now seems clear that some of our fail- 
ures were not due to the fact that we were giving too much fat, but 
that we were not supplying in the protein given the amino-acids re- 
quired for normal growth. 

The success which has attended the use of formulas made from 
whole milk has not been entirely due to the fact that the fat dis- 
turbances have been avoided, but that in these formulas by greatly in- 
creasing the protein we have come much nearer supplying the in- 
fant's actual amino-acid needs of growth, especially in lysin and cystin. 
The excess of other protein food apparently is not injurious. 

We have seen thus far (1) that the digestion of the protein of cow's 
milk is a much easier matter than was formerly supposed; (2) that 
while injury may without question be done by high protein feeding, 
this is very unlikely to occur, unless amounts much in excess of those 
commonly used in infant feeding are administered; (3) that in such 
amounts we have as yet neither clinical nor laboratory evidence to 
show that protein is harmful; (4) that although an infant receiving 
breast milk takes rather less than 7 per cent of his calories as pro- 
tein, this cannot be taken as an exact criterion of how much protein 
should be administered when cow's milk is the food; (5) that the 
deficiency of cow's milk casein in certain essential amino-acids may 
be made up by giving an excess of this protein. 

There remains for brief consideration the clinical use which may 
be made of these facts, not now in the feeding of healthy infants, 
but in the diet of those who are suffering from the most common forms 
of digestive disturbances — intolerance of fat or carbohydrates or both. 
The great advantages of high protein feeding and the extent to which 



32 DISEASES OF CHILDREN 

proteins are borne we have only recently appreciated. That an infant 
of four or five months could easily tolerate a milk mixture containing 
as much as 3.5 or even 4 per cent of protein has been to most of us 
a surprise, especially when the protein given is nearly all casein. In 
our experience, in acute intestinal disturbances it is the carbohydrates 
that are most frequently at fault, and sugars are even more badly borne 
than starches. Milk sugar seems then to cause more disturbance than 
any other form of carbohydrate. It is for such cases that Finkel- 
stein's milk modification — best translated into English as protein milk 
(q. v.) — is so valuable. Its usefulness is seldom enhanced by preparing 
it from skimmed milk, but, in my experience, rather the contrary. For 
its relatively high fat is usually tolerated without difficulty when low 
sugar is given. This preparation is to be regarded as a therapeutic 
agent, not a method of infant feeding, but it is one of the most valua- 
ble additions to our resources that has been made in recent years. 

Physiology and Pathology of the Digestion of the Carbohydrates in 

Infancy'" 

Physiology; Ferments. — Zwiefel, 1874, and Ivorowin, 1875, were un- 
able to find a diastatic ferment in the pancreas of the newborn, and 
to this fact is due most of the misconceptions concerning the power of 
digesting starch in infancy. The work which corrected this impres- 
sion will be quoted later. 

Saliva. — Zwiefel found diastase in the parotid gland of the newly 
born but was unable to find it in the submaxillary. Ibrahim, after a 
prolonged piece of work, found it in both the parotid and submaxillary 
glands, its action being stronger in the former than in the latter. Di- 
astase was found much earlier in fetal life in the parotid than in the 
submaxillary, traces being found in the former at the fourth and in the 
latter at the sixth month of fetal life. The diastase of the parotid is the 
earliest digestive ferment found in the embryo. 

A diastatic ferment can always be found in the saliva of healthy 
infants. The diastatic action of saliva may continue in the stomach as 
long as two hours after feeding. 

Stomach. — Ibrahim is the only worker who has examined the gastric 
mucous membrane of the newborn for the carbohydrate splitting fer- 
ments, and he has been unable to find either lactase, maltase or invertin. 

Pancreas. — Moro was able to demonstrate the presence of amylo- 
lytic ferment in the pancreas of newly born babies when the pancreas 
was thoroughly extracted, and thus disproved the earlier work of Zwie- 
fel and Korowin. Ibrahim never failed to get the ferment in a six 



"See foot note p. 26. 



PREVENTION AND CONTROL OF DISEASE 33 

months' fetus when he tested the action of the ferment on starch meal. 
He was, however, unable to find it when he tested soluble (i. e., cooked) 
starch. 

Ibrahim was unable to demonstrate invertin and lactase in the pan- 
creas of the newborn or older babies, but he was usually able to dem- 
onstrate maltase in the newborn and always in older children. Maltase 
may also be found in the blood. 

Small Intestine. — The mucous membrane of the small intestine con- 
tains amylolytic ferments. 

Lactase, the ferment which splits milk sugar, has been repeatedly 
found in the mucous membrane of the small intestine. Ibrahim always 
found it in the small intestine and meconium of newly born babies, but 
was unable to find it in premature infants. He says, however, that 
his method of determining lactase is not capable of demonstrating small 
amounts. Lactase is more abundant in the young animal than in the 
adult. 

Pautz and Yogel found maltase, the ferment which splits malt sugar, 
in the small intestine of infants. 

Invertin, the ferment which splits cane sugar, was found in the se- 
cretions of the small intestine of the newborn by Miura, and Ibrahim 
was always able to demonstrate its presence both in the intestinal 
mucous membrane and in the intestinal contents of all fetuses. 

Large Intestine. — It is difficult to wash the large intestine free from 
meconium, and the results of the examinations of its mucous membrane 
are variable, as the tables of Miura, Pautz and Vogel show. It is, there- 
fore, impossible to say, whether it contains ferments or not. 

Stools. — Pottevin found an amylolytic ferment in the meconium. 
Kerley, Mason and Craig were able to demonstrate the presence of a 
strong amylolytic ferment in the stools of very young babies, the possi- 
bility of the bacterial fermentation of starch being excluded. There 
is a larger amount of diastase in the stools of breast-fed babies than 
in those of the bottle-fed, which Hecht believes to be due to the fact 
that the intestinal contents of the breast-fed baby pass more quickly 
through the intestinal canal than do those of the bottle-fed baby. 

The power of digesting starch, while occasionally absent, is, there- 
fore, almost always present both in the fetus and in the newly born. 
Hedenius' experiments show that it is less powerful in young babies 
than in later life. Young babies are nevertheless able to adapt them- 
selves to a food rich in carbohydrates. There is, according to Moro, 
a rapid increase in the power of digesting starch during the first week 
of life. The baby, therefore, has a power of digesting starch at birth 
which gradually increases in strength as the baby grows older. Ac- 



34 



DISEASES OF CHILDREN 



cording to Finizio, it is twice as strong at eight months as it is at 
birth, while at twelve months it is almost as strong as at three years. 

The question whether the carbohydrate-splitting ferments are af- 
fected by disease has been answered only in part. Orban found by 
animal experimentation that an injured intestinal mucous membrane 
contained no lactase, and that the stools of babies ill with enteritis 
contained no lactase. Langstein and Steinitz, on the other hand, 
always found lactase in the stools of babies ill with enteritis, whether 
mild or severe, acute or chronic. 

Forms of Carbohydrates.— The carbohydrates used in infant feed- 
ing may be divided into the following groups : 



Milk Sugar Group Cane Sugar Group 



Lactose (milk sugar) 

t 

Dextrose + Galactose 



Saccharose (cane sugar) 

I 

Dextrose + Levulose 



Malt Sugar Group 



Starch (amylum) 

I 
Dextrin (amylo- 
dextrin) 

I 
Erythro- and Aeliro- 
dextrin 

t 

Maltose (malt sugar) 

$ 

Dextrose + Dextrose 



Poly- 
saccharide 



Di- 

saccharide 

Mono- 
saccharide 



Digestion of Carbohydrates. — The carbohydrates are broken down 
during digestion into the simplest forms of sugar, the monosaccharides, 
by the various ferments described above. According to Eohrmann 
a considerable amount of the disaccharides may pass into the intes- 
tinal mucous membrane and these be split into monosaccharides. The 
monosaccharides are carried by the portal vein to the liver, where 
they are transformed into glycogen, the only difference being that dex- 
trose is more easily converted than levulose or galactose. The pan- 
creas has some influence on this process, because extirpation of the 
pancreas in dogs results in sugar in the urine and interferes with 
the formation of glycogen in the liver. The liver actually has the 
property of forming glycogen from sugar. 

The purpose of the splitting of the poly- and disaccharides into 
monosaccharides is to prepare them for use inside the body, because 
the unsplit carbohydrates are not burned up in the body but are ex- 
creted in the urine. The transformation of sugar into glycogen, which 
is deposited in the liver and muscles, is of great importance, because 
this glycogen can be broken down again into sugar according to the 
needs of the body. The monosaccharides are absorbed more quickly 
than the disaccharides. 



PREVENTION AND CONTROL OF DISEASE 35 

A large part, of the digestion and absorption of the carbohydrates 
takes place in the upper part of the small intestine, bnt splitting 
and absorption may also take place in the large intestine. 

There is normally about 1-10 per cent of dextrose in the blood. 
The slightest disturbance of the regulating apparatus will cause 
a hyperglycemia which results in glycosuria. A deficit of sugar in 
the blood is made up from the glycogen deposits. 

Albertoni and Hedon found that sugars have a purgative action when 
they are given in large enough amounts. This action is more marked 
when they are taken in concentrated solution. All sugars have this 
action, the difference between them being only in degree. They found 
that glucose and cane sugar are much more quickly absorbed than 
lactose, and that the former has less of a purgative action than the 
latter. 

Little or no sugar can be found in the stools under normal condi- 
tions, but when the food passes rapidly through the intestinal canal, 
as it does when peristalsis is rapid as the result of disease or indiges- 
tion, sugar can be found in the stool (Hecht). Usually only the prod- 
ucts of the decomposition of sugar can be isolated. 

Hedenius fed babies with milk mixed with wheat flour, oat gruel 
or Keller's malt extract and measured the amount of carbohydrates 
ingested, the amount in the stools, and their acidity. He found that 
when simple cereals were used, less carbohydrate was found in the 
stools than with complicated mixtures and that the more carbohydrate 
in the stool, the greater its acidity. He never found more than 3 per 
cent of the ingested carbohydrate in the stool in any instance. Kel- 
ler has shown that carbohydrates make the digestion of protein more 
complete. 

Metabolism of Carbohydrates. — Numerous observations have shown 
that when milk sugar is injected directly into the circulation it may 
be completely recovered in the urine. Grosz was never able to de- 
tect milk sugar in the urine of healthy babies, but found it in the 
urine of those suffering from gastrointestinal disease, in which there 
was presumably an absence of lactase in the intestine. Langstein 
and Steinitz repeated Grosz 's experiments and in certain instances 
found lactase in the stools at the same time that sugar was being 
excreted in the urine. This sugar was, moreover, not always lac- 
tose, but sometimes galactose, one of the products of the splitting 
of lactose. They tried to explain this as follows : that some of the 
sugar passes through functional or anatomic lesions of the intestinal 
wall before it is completely broken up and is excreted in the urine 
as an intermediary product of metabolism. 



36 DISEASES OP CHILDREN 

Mendel and Kelimer have shown that when cane sugar is intro- 
duced subeutaneonsly into dogs or eats in doses of 1 to 2 grams per 
kilogram of body weight, it is not completely recovered in the urine. 
The quantity excreted amounts, as a rule, to more than 65 per cent 
of that introduced. The excretion begins within a few minutes and 
is usually completed within thirty-six hours. Fisher and Moore 
draw attention to the possibility that the sugar thus introduced may 
be excreted through the walls of the alimentary tract and there be 
digested. These views are supported by Japelli and D'Errico, who 
conclude from their experiments on dogs that when cane sugar is in- 
troduced directly into the circulation the quantity eliminated in the 
urine is never equivalent to the amount injected. This causes both 
glycosuria and saccharosuria, the former disappearing first. The 
blood has no power of converting cane sugar. According to these 
writers, cane sugar introduced intravenously is eliminated into the 
alimentary tract through the gastric mucosa, the salivary glands and, 
to an insignificant degree, through the bile. The subsequent fate 
of this component is obvious. 

According to Finkelstein, sugars may cause fever. This so-called 
sugar fever has been studied especially by his pupils. Leopold found 
that 43 per cent of the babies tested with lactose, 47 per cent of 
those with glucose, 42 per cent of those with saccharose (cane sugar), 
and 33 per cent of those with maltose, reacted with fever. This fever 
was always accompanied by diarrhea, and in none of the cases tested 
in which the stools remained normal did the sugar cause fever. 

The limits of assimilation of the different sugars vary and are as 
follows : 

Grape Sugar. — In babies, about 5 grams per kilogram (Langstein 
and Meyer). 

Grape Sugar. — In one-month baby, 8.6 grams per kilogram (Green- 
field). 

Galactose. — No accurate data. 

Levulose. — Lower for babies than adults. One gram per kilogram 
(Keller). 

Maltose. — Over 7.7 grams per kilogram (Reuss). 

Lactose. — 3.1 to 3.6 grams per kilogram (Grosz). 

Cane Sugar. — Probably about the same as lactose (Reuss). 

Escherich divides the digestive disturbances of infancy into two main 
types: (a) Fermentation with the formation of acid products, and (5) 
putrefaction with the formation of alkalies. These two processes are an- 
tagonistic to one another, the basis of fermentation being carbohydrates 
and, of putrefaction, protein. An excessive preponderance of one over 
the other may do harm. Fermentation results in an excessive formation 



PREVENTION AND CONTROL OF DISEASE 37 

of acids, especially of lactic acid from lactose. This may cause a large 
number of stools as the result of the increased peristalsis and the flow 
of serous fluid or cellular exudate. Razenski has shown that in babies 
sick with what he calls "dyspepsia intestinalis acida lactorum" there 
is an increased acidity of the intestinal contents and that the utili- 
zation of fat is diminished. Meyer and Leopold intimate that a sugar 
indigestion may cause the appearance of casein curds. 

Finkelstein and Meyer believe that milk sugar is the primary cause 
of the fermentative dyspepsias of infancy and that when there is a 
disturbance of the utilization of fat in these conditions it is a secon- 
dary manifestation. They claim that these dyspepsias can be relieved 
by the long-continued diminution of the carbohydrates in the food 
and quickly cured by the withdrawal of milk sugar and the adminis- 
tration of large amounts of casein (Eiweissmilch). In general, the 
fermentation of the sugar depends upon the relation between the 
casein and the sugar in the food. They advise the administration of 
other easily assimilable and consequently little fermentable carbo- 
hydrates, such as maltose, in place of lactose, after the disappearance 
of the acute symptoms. Birk and Reuss and Sperk have confirmed 
their observations. Braumuller called attention, however, to the dan- 
ger of the sudden addition of sugar to the diet after it has been 
withdrawn and large amounts of casein given, believing that under 
these conditions the ability to form the ferments necessary to take 
care of sugar is practically abolished. 

Kendall has shown that the colon bacillus, like the diphtheria and 
tetanus bacilli, causes fermentation or putrefaction according to 
whether it is in a carbohydrate or protein medium, that it attacks the 
sugar in preference to the protein of the medium and that until the 
carbohydrate is used up the protein is shielded from attack. The 
products of the fermentation of carbohydrates are acid. He also 
showed that the Shiga bacillus produces toxin only when the medium 
has an alkaline reaction. He, therefore, proposed feeding babies ill 
with bacillary d3 T sentery with an easily fermentable carbohydrate in 
order to change the character of the bacterial activity in the alimen- 
tary canal from the proteolytic to the fermentative type. The result 
is to stop further formation of toxin. This was done by feeding the 
babies a 5 per cent lactose solution, under the influence of which 
the dysentery bacillus and streptococci tend to disappear. 

Fat Metabolism 

The infant obtains its required amount of fat elements in the breast 
or bottle milk. But whereas the infantile system assimilates almost 
96 per cent of the fat of breast milk, it absorbs only 80 per cent of that 



38 DISEASES OF CHILDREN 

of cow's milk. Furthermore, the daily loss of fat by infants fed on 
mother's milk is only half as great as that of cow's milk. As in adults 
so in children fat plays an important role in the maintenance of body 
heat and, if combined with proteids, it saves nitrogenous waste and to 
a certain extent replaces the carbohydrates. 

The fats of the milk pass unchanged into the duodenum. Here they 
are partly emulsified and in part split up by the pancreatic juice into 
fatty acids and gl3 T cerine, and thus largely absorbed by the intestinal 
villi. The unassimilated fat passes out with the feces as neutral fats, 
fatty acids and soap. 

L. E. Holt, A. M. Courtney and H. L. Fales, have made a very ex- 
haustive study of the "Fat Metabolism of Infants and Young Chil- 
dren" (Am. Jour. Dis. Child. Vol. xvii and xviii, 1919) and arrived at 
the following conclusions regarding 

FAT RETENTION AND EXCRETION IN 
RELATION TO DIET 

I. Fat in the Stools of Breast Fed Infants 

1. The fat of the stools of normal breast fed infants, according to 
their observations, averaged 34.5 per cent of the dried weight and 
frequently was as high as 50 per cent. 

2. The soap fat in the best stools predominated over the other forms 
of fat, averaging 57.8 per cent of the total fat, as determined on the 
dried stool. The average stool of the normal breast fed infants showed 
a soap fat of 43'. 1 per cent of the total fat, as determined on the dried 
stool, which would correspond to over one-third of the total fat of 
the fresh stool. 

3. The neutral fat in the best stools averaged 15.9 per cent of the 
total fat; in the average stool the neutral fat was 20.2 per cent of the 
total fat. The amount of neutral fat is not affected by the drying 
process. 

4. No constant relation was shown between the per cent of fat in 
the mother's milk and the per cent of total fat and its distribution in 
the stool. 

5. With a higher total intake of fat, the fat per cent and the soap 
fat in the stool were somewhat increased. 

6. A range of fat absorption from 90.3 to 99.2 per cent of the intake 
was found in healthy breast fed infants. 



PREVENTION AND CONTROL OF DISEASE 39 

II. Fat in the Stools of Infants Fed on Modifications 

of Cow's Milk 

1. The material presented in this article comprised the results of 
analysis of 128 stools of seventy-seven infants whose ages ranged from 
2 to 18 months, fed on modifications of cow's milk. 

2. The average fat per cent of the dried weight in normal stools 
was 36.2. The hard, constipated stools showed no variation from this 
figure. In the stools not quite normal in appearance the average fat 
per cent was slightly lower. In severe diarrhea the fat per cent of 
dried weight was much higher, reaching an average of 40.7 per cent. 

3. The soap per cent of total fat was very high in both normal 
and constipated stools, averaging, respectively, 72.8 and 73.8 per cent. 
As the stools became less normal in appearance the soap fat diminished 
rapidly and averaged in the loose stools only 30.6 per cent of the 
total fat, in the diarrheal stools 12.4 per cent, and in those of severe 
diarrhea only 8.8 per cent of the total fat. 

4. The neutral fat was less than 10 per cent of the total fat in 
normal and constipated stools. It increased as the soap fat diminished 
and in diarrheal conditions made up about 60 per cent of the total fat 
in the stool. 

5. The free fatty acids constituted about 17 per cent of the total 
fat of normal and of constipated stools. It was increased somewhat 
as the stools became less like the normal and in the diarrheal stools 
was over 30 per cent of the total fat of the stool. 

6. No definite relationship was shoAvn between the daily fat intake 
and the per cent of fat or the distribution of fat in the stool. 

7. The average per cent of the fat retained with normal stools 
was 91.3 per cent of the intake. The retention was but little lower 
when the stools were somewhat harder or softer than normal, or 
were not homogeneous, or contained more or less mucus without being 
distinctly watery. As the water in the stools increased, the per cent 
of retention dropped markedly, reaching in severe diarrhea 58.4 per 
cent of the intake. 

8. There was no striking relation between the fat intake and the 
per cent of the intake retained, except when the intake was abnor- 
mally low. 

III. Fat in the Stools of Children on a Mixed Diet 

1. In the normal or constipated stools of older children whose diet 
consisted of milk alone or milk with bread and cereal the fat per- 
centage of dried weight averaged 30.7, which is lower than the average 



40 DISEASES OF CHILDREN 

found for similar stools of infants taking modifications of cow's milk. 
The soap percentage of total fat averaged 60.9, which was somewhat 
lower than that found in the stools of the infants. 

2. The normal and the constipated stools of children on a mixed 
diet showed almost identical average values both for fat percentage of 
dried weight and for distribution of fat. The fat percentage of dried 
weight averaged, respectively, 18.0 and 20.1, and the soap averaged, 
respectively, 45.1 and 47.9 per cent of the total fat. These values 
were much lower than those found when the diet contained little or 
no solid food. 

3. In the acid abnormal stools of children on a mixed diet the fat 
averaged 15.1 per cent of the dried weight. Both the fat percentage 
of dried weight and the soap percentage of total fat were much lower 
than in normal stools and the values for fatty acids and for neutral 
fat were higher. 

4. "With rachitic children the fat percentage of dried weight aver- 
aged 34.7 in the alkaline stools, and 24.6 in the acid stools.. The values 
were higher than those found for corresponding types of stools of 
normal children. The proportions of soap, fatty acids and neutral fat 
were not significantly different from those for normal children. 

5. The stools of children suffering from chronic intestinal indiges- 
tion showed a much higher fat percentage of dried weight than those 
of normal children; the average for alkaline stools being 36.4 per cent, 
and for acid stools 35.3 per cent, The average percentage of neutral 
fat was lower in both alkaline and acid stools of these children than in 
the stools of normal children. The fatty acids were higher than 
normal, much higher when the reaction of the stools was acid. 

6. The average fat loss in the stools of normal children varied 
between 2.6 and 3.0 gm. in all the groups studied, being highest in the 
stools of children whose diet contained the smallest proportion of solid 
food and the largest proportion of milk. 

7. The normal children on mixed diet retained on the average about 
94 per cent of the fat intake, regardless of the type of stool. The 
average actual retention was about 38 gm. daily. The children with 
little or no solid food and a smaller fat intake showed a lower actual, 
and a somewhat lower percentage retention than those on a general 
mixed diet. 

8. The rachitic children showed a slightly larger fat loss in the 
stools than did the normal children ; their intake, however, was higher. 
Their actual retention, therefore, equalled or exceeded that of the 
normal children, and their percentage retention was only a little lower 
than the normal average. 



PREVENTION AND CONTROL OF DISEASE 41 

9. The fat loss in the stools of the children suffering from chronic 
intestinal indigestion was very great, averaging 7.3 gm. daily in the 
alkaline stools and 8.0 gm. in the acid stools. Both the actual and 
percentage retention were much lower than normal. The percentage 
of the intake retained averaged 79.1 when the stools were alkaline 
and 77.7 when they were acid. When the intake of fat was very high 
the actual retention was usually as high as that found for normal 
children. 

IV. The Digestion of Some Vegetable Fats by Children 
on a Mixed Diet 

1. The stools of children receiving a considerable proportion of 
vegetable fat did not differ essentially in appearance from those of 
children receiving mainly milk fat, although they were usually some- 
what softer. 

2. The fat percentage of dried weight of the stools averaged some- 
what lower when nut butter was taken, and somewhat higher when 
corn oil was taken, than when the fat in the diet was mainly milk fat; 
and when large quantities of corn oil were included in the diet the 
average was much higher. 

3. The soap percentage of total fat in the stools was usually a little 
lower and the neutral fat a little higher with vegetable fat than when 
the fat of the diet was mainly milk fat. 

4. When nut butter was taken the fat excretion in the alkaline 
stools was lower and in the acid stools it was higher, than when the 
diet did not contain vegetable fat. When corn oil was taken in con- 
siderable amounts the fat excretion in the stools was higher than when 
the fat of the diet was mainly milk fat. However, the total fat intake 
when corn oil was included in the diet was very large and the actual 
retention of fat always much higher than the normal average for 
mixed diet. When vegetable fat formed a considerable part of the 
total fat intake, the percentage of the fat intake retained was usually 
higher than the normal average. In a few instances when the stools 
were acid and in a few when large amounts of corn oil were taken, 
the percentage retained was low. 

5. The individual children observed for considerable periods with 
changes in the kind and amount of fat intake showed quite as good 
digestion of vegetable fat as of corresponding amounts of milk fat 
and no unfavorable effect on general health and nutrition was ob- 
served. No children were kept long enough on a diet presumably de- 
ficient in fat-soluble A to warrant any conclusions as to the effect of 
such a diet upon growth and health. In the case of one child who for 



42 DISEASES OF CHILDREN 

five weeks was on a diet in which there was no definite source of fat- 
soluble vitamin, 95 per cent of the fat of the diet being corn oil, he 
ceased to gain in weight, but showed no loss and the general health 
continued excellent. The fact may not be without significance that of 
six children, 80 to 95 per cent of whose fat intake was vegetable fat, 
two developed styes and two others eczema upon the face, which dis- 
appeared when the diet was changed to include milk fat. 

Woman's Milk Feeding 

Woman's milk* is a highly nutritious, biologically as yet some- 
Avhat mysterious product, destined by nature to serve as the food 

B 




k 



«m 



Fig. 1. — Microscopic appearances of woman's milk. (After Fleischman.) A. 
Poor milk showing preponderance of large fat globules and a paucity of fat. B. 
Normal milk, showing the preponderance of medium-sized fat globules. C. Poor 
milk; a paucity of fat and an almost granular state of the fat globules. 

*For its Approximate Composition see footnote, p. 48. 



b n 

~ o 

o 



2 t"* 



n S 



2 H 




PREVENTION AND CONTROL OF DISEASE 43 

supply alike for the rich and the poor, the weak and the strong 
infant under nine months of age. It not only complies with 
the aforementioned qualitative requisites, but being ready for imme- 
diate consumption — without previous pasteurization, sterilization or 
modification — at all hours of the day and at all seasons of the year, it 
is also the most convenient and satisfactory food from an economic 
point of view. Infants reared on woman's milk are almost invariably 
healthier, stronger and less troublesome than those that are bottle 
fed. With suitable management they are, as a rule, free from gastro- 
enteric affections, scurvy and rickets, and present greater power of 
resistance to communicable diseases. 

Maternal Nursing. — For the reasons just given, and in view of the 
facts that wet-nurses are expensive luxuries, are often unreliable, and 
may at some time during the nursing period, through unscrupulous 
and impure contact, contract and convey a disease to her charge, it is 
the solemn duty of every healthy mother to endeavor to nurse her 
offspring, wholly or partially, even if it be only for a brief period of 
time. 

Successful maternal nursing presupposes, in addition to general good 
health of the mother, well-developed breasts and nipples and an ample 
supply of milk. These qualifications are rarely met to perfection in 
women of large cities, where the extravagances of extreme wealth or 
the misery of extreme poverty sap their vital forces. A great deal, 
however, can be accomplished by judicious management of the mother 
during pregnancy and parturition. 

The prospective mother should be placed in the most healthful physi- 
cal and mental condition. Her diet should be liberal, her living rooms 
spacious and airy and her surroundings cheerful. She is to be free 
from anxieties of a livelihood and the pompous frivolities of wanton 
society. The primipara should be taught to realize that pregnancy 
and parturition are physiologic processes, ordinarily devoid of peril- 
ous complications or sequelae. 

Toward the end of pregnancy the breast nipples should be elongated 
by gentle traction with the fingers or pump, and cleansed and hardened 
by means of hot boric acid solutions, cognac, glycerite of tannin, and 
the like. To insure an ample supply of breast milk after delivery, in 
addition to complying with the aforementioned suggestions, a liberal 
fluid diet, consisting principally of rich cow's milk, cornmeal and oat- 
meal gruel cooked in milk, malted milk, etc., forms the most efficient 
adjuvant, At a later period the dietary of the nursing mother should 
be increased by a liberal allowance of meat, eggs, vegetables and other 
nutritious foodstuffs to which she was ordinarily accustomed. 



44 



DISEASES OF CHILDREN 



Light outdoor exercise, regulation of the bowels, avoidance of fa- 
tigue and nerve disturbances, all serve well to improve the health of the 
mother and the quality of her milk and indirectly to promote the wel- 
fare of the baby. 

One other special advantage of maternal- over wet-nursing is the 
benefit the newborn derives from the consumption of the provisional 
milk secretion — the colostrum. This deep yellow, strongly alkaline 
and albuminous fluid which forms the mammary secretion during the 
first three or four days after labor, not only acts as a laxative — which 
is badly needed, but being small in quantity it also serves to moderate 
the greedy appetite of the infant and prevents early overfeeding, the 
usual cause of infantile colic. 

The nursing of the baby is generally begun about eight hours 
after delivery, or later if the mother has not fully recovered from the 
painful and fatiguing ordeal. During the first few days the infant is 




Fig. 2. — Breast pumps. 

applied to the breast every three or four hours and afterwards every 
two and a half or three hours. It should not be awakened for a 
feeding if sound asleep (except when very weak and delicate), and, 
unless very restless, should be left alone from 10 p. m. to 5 a. m. It 
should be nursed from fifteen to twenty minutes at a time, alternately 
on one and the other breast, or on both breasts if the milk secretion 
is scanty. From six weeks on the infant should be fed every three 
hours, and less frequently when it reaches six months of age. Between 
nursings the baby may receive a few ounces of warm water. 

Before and after each feeding the breast nipples should be carefully 
cleansed with a warm saturated solution of boric acid. 

If the breast nipples are short, sunken or cracked, we must tempo- 
rarily resort to an artificial nipple or breast pump (Fig. 2). The lat- 
ter device is also employed where the infant is too weak to pull, or 
refuses to make an effort to do so. In very delicate infants, e. g., pre- 



PREVENTION" AND CONTROL OF DISEASE 



45 



matures, it is often necessary to withdraw the breast milk with a pump 
and to administer it by means of a spoon or dropper. 

With the suggestions here offered the majority of healthy mothers 
will be able to nurse their offspring, provided they are sufficiently 
encouraged by the physician and the enormous advantages of maternal 
breast feeding are thoroughly explained to them. 

When an infant does not thrive on breast milk, it is imperative, 
before resorting to another infant food, to analyze carefully the breast 
milk, and, if possible, to overcome the difficulty. We should determine : 

1. The Quantity — This can readily be learned by extracting the milk 
supply of one or both breasts, or by weighing the infant before and after 



I 

cc 

6D"F 

500-|g 

45D-J 

*oo-lf 
350 ^g 
3Q04t 
250-lf 
20D-J 
I5D = 



:z- 






z 



607 

SOO-p 
45Q-f§ 
♦00 -j§ 
350 S 
300-g 
250-1 
200 -§ 
150 -B 
IDO-g 

rl 



Fig. 3. — Holt 's milk testing apparatus. 



nursing and noting the difference in weight — the gain in ounces in- 
dicating the amount of milk it has obtained. 

2. The Quality. — As the sugar is usually found to be normal in all 
cases, the tests are ordinarily limited to the fat and protein contents 
of the breast milk. After obtaining an ounce of what is called "middle- 
milk" (?. e., the milk collected after 1 or 2 ounces had been withdrawn) 
or of the entire breast supply, we determine the following qualifications : 

(a) Reaction. — Fresh breast milk should be alkaline or neutral and 
may be tested with litmus paper. 

(b) Specific Gravity. — This should be about 1.030, taken by means of 
a lactometer, at a temperature of 65° to 72° F. 

(c) Fat Content.— The cylinder of Holt's milk set (Fig. 3) is filled 
with the sample of breast milk up to the zero mark and allowed to 



46 



DISEASES OF CHILDREN 



stand for twenty-four hours in a room temperature of 70° F. The per- 
centage of cream is then read off, bearing in mind that the ratio of the 
cream to the fat is approximately 5 to 3, *. e., 5 per cent of cream equals 
3 per cent of fat. 

(d) Proteids. — The amount of proteids is approximately determined 
by the amount of fat and the specific gravity of the milk, i. e. t high spe- 
cific gravity, high proteids; low specific gravity, high fat. Holt's accom- 
panying table explains the application of this principle: 





Specific 


Cream 


Proteid 




Gravity 


(24 Hours) 


(Calculated) 


Average 


1.031 


7 


1.5% 


Normal variations 


1.028-1.029 


8%-12% 


Normal (rich milk) 


Normal variations 


1.032 


5%-6% 


Normal (fair milk) 


Abnormal variations 


Low (below 1.028) 


High (above 10%) 


Normal or slightly 
below 


Abnormal variations 


Low (below 1.028) 


Low (below 5%) 


Very low (very poor 
milk) 


Abnormal variations 


High (above 1.032) 


High 


Very high (very rich 
milk) 


Abnormal variations 


High (above 1.032) 


Low 


Normal (or nearly so) 



While, as a rule, the breast milk of the modern mother is characteristic 
for its paucity, we occasionally come across breast milk that is too rich 
in quality, especially as regards the fat content. In the majority of 
such instances, if the excess in fat is detected early, it can readily be 
corrected (by reducing the mother's diet, encouragement of active 
exercise, etc., or by resorting to partial nursing) before any appreciable 
harm has been done to the infant. In some cases, however, the abnor- 
mality of the milk is not discovered until the infant is suffering from 
"fat indigestion" (diarrhea with curds of fat, eructations, colic and 
possibly loss of weight), and one is often in a quandary as to what is 
best to do. An attempt may be made to thin the breast milk by admin- 
istering to the infant before each nursing X/ 2 or 1 ounce of plain or 
cereal water. Or the baby is allowed to nurse at the breast only a few 
minutes and is then given an ounce or two of diluted skimmed milk to 
make up the quantity to satisfy the baby. If these procedures and the 
dieting of the mother fail, and the child is progressively getting worse, 
we must either engage a wet-nurse or put the baby on a suitable artificial 
food. 

Where the milk supply is deficient, partial nursing should be insisted 
upon, preferably alternating one breast- with one bottle-feeding. 

Wet-Nursing. — Wet-nurses at best are an evil, but often indispen- 
sable, where mothers will not, cannot, or must not nurse their own off- 
spring. If the mother cannot nurse her baby because of quantitative 
or qualitative insufficiency of her milk, there is no urgency of securing 



PREVENTION AND CONTROL OF DISEASE 47 

a wet-nurse, as the milk may be improved by a richer diet and better 
care of the mother, or the infant may receive daily two or three feed- 
ings of properly modified cow's milk. In the event, however, that the 
mother is utterly unable to nurse her baby or is prevented from doing 
it through disease (tuberculosis, cancer; acute, greatly debilitating af- 
fections; advanced kidney or heart disease; local inflammation of the 
breast, psychoses and the like) or pregnancy, a wet-nurse is the best 
substitute. The wet-nurse to be chosen must undergo a very careful 
physical examination, first as to the secreting quality of the breasts 
and the condition of the nipples, and next as to her general health. 

The secreting quality of the breast is best tested by "stripping," 
i.e., by grasping the upper portion of the nipple with the thumb and two 
fingers, and, while moving the fingers briskly forward, exerting uni- 
form but gentle pressure. With this manipulation the milk should 
escape from the breast in several even jets for from fifteen to thirty 
seconds. Too much reliance should not be placed upon the form of 
the breast, for even pendulous, cylindrical, or conical breasts are occa- 
sionally poor milk producers. On the other hand, an abundance of 
glandular parenchyma offers more reliable guarantee as to its secreting 
power. The physician should be on his guard that the abundance of 
milk be not the result of the breast having been allowed to fill up for 
several hours previous to the examination — a fact recognized by the 
presence of pain on pressure and intense distention of the mammary 
ducts. The nipples should be hard, long and bulky, free from severe 
erosions or fissures. 

The quality of the milk is not nearly as essential as the quantity, 
since the former can usually be improved upon by suitable diet and 
good hygiene. 

The following diseases render a wet-nurse useless: Tuberculosis, 
whether local or general; syphilis, in all its stages (not necessarily con- 
traindicated in the mother) ; noncompensating heart disease; grave af- 
fections of all other bodily organs; profound anemia; intractable, 
communicable skin, hair, and eye diseases; gonorrhea; suppurative 
processes of the bones; mastitis (not necessarily contraindicated in the 
mother) ; ozena, drug addiction, psychoses, and epilepsy. 

The possible presence of syphilis should receive special attention. 
Corona veneris, bony tumefactions, nasopharyngeal patches, old ulcers 
and scars, enlarged glands (especially paramammary, epitrochlear, and 
inguinal) should invariably arouse the suspicion of the examiner. Ev- 
ery wet-nurse should undergo a Wassermann test. 

The wet-nurse of choice should be one between twenty and thirty 
years, who has given birth to two healthy children and nursed one sue- 



48 DISEASES OF CHILDREN 

cessfully, the age of the last child being nearly the same as the one 
she is about to nurse. The diet of the wet-nurse, the care of her breasts 
and nipples, the mode of living, exercise, etc., should be the same as in 
a nursing mother (q. v.). Sudden changes, however, from dire want to 
superabundance are to be avoided. 

Artificial Feeding 

AVhere maternal nursing is impossible, and wet-nursing impracti- 
cable, there is nothing else left but to resort to artificial feeding. All 
human ingenuity and skill have thus far failed to provide a food for 
infants that is as nutritious, digestible, sterile without interference 
of composition, and as economic as woman's milk. 

Cow's Milk Feeding 

With suitable modification cow's milk forms the best substitute 
for human milk. But it is a poor substitute at best, for not alone 
does human milk vastly differ from cow's milk in the quantitative pro- 
portion of the essential chemical ingredients, but the latter vary 
greatly also qualitatively. Furthermore, human milk contains several 
as yet not fully determined biologic constituents, especially enzymes, 
which are absent in cow's milk. 

To meet the aforementioned requirements of an infant food, cow's 
milk must undergo considerable modification to approach human 
milk in its composition. As may be noted from the comparative 
table* of human and cow's milk, the latter contains about five times 
as much of casein and only half as much of lactalbumin as the former. 
Cow's milk-casein coagulates in the stomach in large firm curds which 
dissolve slowly, the opposite being the case with human milk-casein. 
Human milk-fat forms a finer emulsion than cow's milk-fat, and con- 
tains a much smaller amount of fatty acids. The salt in human milk 
is richer in iron and, finally, human milk is sterile, whereas cow's 
milk when reaching the consumer is replete with bacteria. 

To equalize the numerous differences between the two milks, so as 
to render cow's milk both digestible and nutritious, we have to pro- 
ceed as follows: 

1. Reduce the quantity and coagulability of the casein by : 

*Approximate Composition of Human and Cow's Milk: 

Human Cow's 

Water 87 88 

Solids 13 12 

Caloric value 750 650 

Lactalbumin and g-lobulin 0.75 to 1 . 3 to 0.5 

Casein (combined with calcium) 0.5 to 0.75 3.0 

Fat 4.0 to 4.5 3.5 to 4.0 

Milk sugar 7.0 4.0 to 4.5 

Salts 0.20 0.7 



PREVENTION AND CONTROL OF DISEASE 49 

(a) Dilution ; adding, for example, to 1 ounce of cow's milk 2 ounces of 
either plain, or cereal water, a milk mixture is obtained containing but 1 
per cent of protein, which can readily be assimilated by a young infant. 
Although it has recently been claimed that normal babies can tolerate 
large amounts of cow's milk-casein, we must be cautious to accept these 
views as final, since the medical profession has lately been swayed too 
often from one extreme view to the other. Lime water is usually added, 
by its alkalinity, to delay the coagulation of the casein ; and cereal diluents 
act both as a food and protective colloids which hinder the formation of 
large casein curds. Starches in large quantities, however, are not very 
readily digested by infants under two or three months of age. 

(&)' Addition of sodium citrate, 1 to 2 grains to every ounce of milk 
or cream. Sodium citrate acts by combining with calcium casemate of 
the milk to form calcium citrate and sodium casemate, which, after being 
split up by the rennin, changes into soluble sodium paracaseinate. 

(c) Boiling the milk for five minutes in a single boiler. 

(d) Peptonization (p. 59). 

2. Increase the sugar (which has become reduced in quantity by dilu- 
tion) by the addition of either milk sugar, malt sugar or cane sugar, 
the quantity varying with the degree of dilution of the milk mixture. 
Ordinarily one-half of a teaspoonful for each ounce of the diluent* will 
be required. There is still considerable divergence of opinion as to 
which of disaccharides are best suited for infant feeding. I am inclined 
to think that milk sugar probably serves best for normal babies, while 
maltose or dextrimaltose is best in digestive disturbances. Cane sugar 
is more useful in constipation. 

3. Augment the fat content, if diminished by dilution of the milk, by 
the addition of gravity cream (the cream that is visible on bottle milk 
after setting for six hours or longer) or preferably by using "top milk"! 



*Mode of Preparation of Diluents for Cow's Milk. — Barley water. — One tablespoonful of 
prepared barley (Robinson's) is rubbed up in a little cold water; to this is gradually added a 
quart of boiling-hot water, and the mixture is allowed to boil slowly (simmer), with constant 
stirring, fcr about twenty minutes and then strained. Boiled water is then added sufficient 
to make one quart. Ground groats is especially useful in constipation. 

Oatmeal water.- — One tablespoonful of oatmeal is rubbed up in a little cold water; to this 
is added a pint of boiling-hot water and allowed to boil slowly (simmer) for one to two hours, 
with frequent stirring, and strained through gauze. Boiled water is then added sufficient to 
make one pint. 

Rice zvater. — One tablespoonful of ground rice to a quart of water, prepared the same as 
barley water. 

fTop milk. — Bottle milk, as obtained from reliable milk dealers, contains approximately the 
following percentages of fat and proteids : 

Portion Taken Fat Pkoteids 

Upper y 2 ounce 24.8 3.1 

1 '• 23.1 3.2 

2 " 21.4 3.3 
4 " 20.1 3.4 

" 6 " 18.6 3.5 

8 " 16.7 3.6 

" 12 " 12.1 3.7 

" 16 " 8.4 3.8 

" I 8 " 6.5 3.9 



50 



DISEASES OF CHILDREN 



as a base, i. e. } by taking instead of "whole" milk a sufficient amount of 
milk of the upper 18 ounces of a bottle (which contains 6.5 per cent of 
fat) decanted for this purpose and thoroughly mixed (Fig. 4). 

4. Insure the absence of pathogenic bacteria in cow's milk by ob- 
serving the following suggestions : 

The cow must be free from disease, especially from tuberculosis 
as determined by the tuberculin test and by regular inspection by a 
competent veterinary surgeon. 

The cow r 's entire body should be groomed daily and, immediately 
before milking, the belly, tail, and particularly the udder should be 
carefully cleansed with a clean, damp cloth, with or without soap, 
and dried with a clean towel. 

The milker must be free from communicable affections. Before 
milking, he should thoroughly scrub and dry his hands and don clean 




Fig. 4. — Cliapin's dipper for removal of "top-milk". 

washable, outer garments. He should have a few of these on hand, 
in order to change them should one gown or suit accidentally get 
soiled in the act of milking. 

The milk of each cow should be collected separately in sterile 
utensils and immediately removed from the stable to a clean place 
specially reserved for the keeping of the milk until ready for shipment. 

The milk should be rapidly cooled (below 45° F.) and strained 
through a sterile strainer, then bottled, closed with sterile discs, capped, 
and finally iced — all within an hour or so after milking. 

Owing to the rapid development of bacteria in milk over twenty- 
four hours old, the milk should reach the consumer within this pe- 



PREVENTION AND CONTROL OF DISEASE 51 

riod of time. The milk should further be kept on ice until needed 
for the preparation of the food. 

If, notwithstanding all the prophylactic measures, some doubt still 
remains as to the sterility of the milk, we must subject it to steriliza- 
tion or pasteurization.* 

Laboratory and Home Modification of Cow's Milk 

We have just learned the numerous essential differences of com- 
position that exist between human and cow's milk, and the means by 
which the differences can be removed. Were it merely a question of 
obtaining milk of a definite uniform composition which would at once 
prove suitable for the feeding of infants of all ages, the problem of 
artificial feeding of infants would long have been solved. Unfor- 
tunately this is not the case. Not only must cow's milk be modified so 
that its principal constituents greatly resemble those of human milk, 
but it must undergo also specific modification to meet the digestive 
powers and the requirements of the individual infant at certain periods 
of life — quite a difficult proposition indeed. 

Thanks to the rapid strides of physiologic chemistry and the good 
will and enterprise of several milk dealers and laboratory chemists, 
the modification of cow's milk as an infant food has almost reached 
a stage of perfection. With the help of the laboratory chemist, the 
physician is now enabled to write a prescription for a food mixture 
of definite composition and, like a drug in the pharmacy, have it com- 
pounded exactly as ordered. The latitude of composition is well illus- 
trated in the prescription form on page 52. f 

When "laboratory milk" is not obtainable, and "home modifica- 
tion" has to be resorted to, we may greatly facilitate the process and 
obviate the difficult task of memorizing complicated formulas by se- 



*Sterilization and Pasteurization. — Both of these processes are accomplished by means of 
one of the many sterilizers on the market. In sterilizing, the milk is heated for about fifteen 
minutes at a temperature of 212° F. ; in pasteurising, for about forty minutes at a temperature 
of from 140° to 150° F. For infant-feeding- the milk should undergo the heating process after 
it has been modified and divided in the requisite number of feeding bottles for the entire 
twenty-four hours. The bottles are cooled off by allowing cold water slowly to run through 
the sterilizer; they are then tightly corked, preferably with nonabsorbent cotton, and placed on 
ice until needed for use. Before feeding the bottle should be warmed to body heat. Except 
during the hot summer months or when there is good reason to believe that the milk harbors 
virulent bacteria (e.g., during epidemics of typhoid, cholera, etc.), sterilization is nowadays 
rarely practiced. Pasteurization is usually resorted to instead, particularly since it has been 
demonstrated that this process is less apt to change the taste of the milk, to interfere with its 
digestibility, or to cause constipation. The view held, especially by overenthusiastic, though 
well-meaning, laymen, that pasteurized milk is as nutritious as clean, fresh, raw cow's milk, 
is not based upon scientific observation. Quite the contrary ; pasteurized milk lacks several 
nutritive and protective elements that exist in fresh cow's milk. Hence, its continued use 
greatly interferes with the growth and development of the infant, and is not rarely productive 
of rickets and scurvy, if the baby is fed on milk exclusively. 

fFrom Morse and Talbot's "Diseases of Nutrition." 



52 



DISEASES OF CHILDREN 



Per Cent 



Fats . 



(a) Carbohydrates. 



Lactose (milk sugar) 
Maltose (malt sugar) 
Sucrose (cane sugar) 
Dextrose (grape sugar) 
Starch 



(6) Dextrinizc 



(c) Proteins | Gage ^ 



(d) F'eptonize 

(e) Sodium citrate 

(/) Sodium bicarb 
(g) Lime water 



f % of milk and cream. 
1% 



of total mixture , 



% of milk and cream, 
% of total mixture . . 



% of milk and cream. 
c /c of total mixture . . . 



ill) Lactic acid bacillus 

Heat at ° F. Number of feedings 

Ordered for 

Date 



1. To inhibit the saprophytes of fermentation. 

2. To facilitate digestion of the proteins. 



Amount of each feeding. 



M.D. 



EXPLANATOEY 

(a) It requires 0.75 per cent starch to make the precipitated casein finer. 
(7?) One hour completely dextrinizes the starch. 

(c) In case physicians do not wish to subdivide the proteins, the words "whey" 
and ' ' casein ' ' may be erased. 

(d) Twenty minutes render the mixture decidedly bitter. 

(e) It requires 0.29 per cent of the milk and cream used in modifying to facilitate 
the digestion of the proteins; i.e., the formation of a soft curd; 0.40 per cent to pre- 
vent the action of rennet; i.e., the formation of tough curds. 

(/) It requires 0:68 per cent of the milk and cream used in modifying to favor 
the digestion of the proteins; 1.70 per cent of the amount of milk and cream used 
suspends all action on the proteins in the stomach; 0.17 per cent of the total mix- 
ture gives a mild alkaline food. 

(g) It requires 20 per cent of the milk and cream used in modifying to favor the 
digestion of the proteins; 50 per cent of the amount of milk and cream used sus- 
pends all action on the proteins in the stomach. Five per cent of the total mixture 
gives a mild alkaline food. 

(h) Percentage figures represent the per cent of lactic acid attained when the food 
is removed from the thermostat, When the lactic, acid bacillus is used to facilitate 
the digestion of the proteins, this is the final acidity, as the process is stopped by 
heat at this point. When the bacillus is used to inhibit the growth of saprophytes 
the acidity may subsequently increase to a variable degree, as the bacilli are left 
alive; 0.25 per cent lactic acid just curdles milk; 0.50 per cent gives thick curdled 
milk; 0.75 per cent separates into curds and whey. 

lecting a "standard" milk formula of simplest composition (1:1, i.e., 
1 ounce or its multiple of milk to 1 ounce or its multiple of a diluent) 
and preparing the other milk mixtures by modifying this "standard" 
formula. 



PREVENTION AND CONTROL OF DISEASE 53 

Directions. — 1. Bear in mind the standard formula (1:1), which is 
intended for an infant three months old. 

2. For infants under three months increase about every month down- 
ward the diluent by 1 ounce or its multiple, using "top milk" (upper 
18 ounces) as a base and plain water as the diluent. 

3. For infants over three months of age, increase every two months 
upward the milk by 1 ounce or its multiple, using "whole milk" as 
a base and cereal water as a diluent. 

4. Add to each ounce of the diluent from % to y 2 teaspoonful of sugar 
(milk, malt or cane sugar) and 1 teaspoonful of lime water. 



1:5 




2:1 


one week 




five months 


1:4 




3:1 


two weeks 


Standard Formula 
milk 1 : 1 diluent 


seven months 


1:3 


three months 


4:1 


one month 




nine months 


1:2 




5:1 


wo months 




eleven months 



Milk modified in accordance with these suggestions yields milk mix- 
tures of the following approximate composition: 

For an infant one week old (1:5). 

Top milk 2-2/3 ounces Proteins 0.50 

Lime water 3 drams Sugar 6.00 

Water 13 ounces Fat 1.00 

Sugar 4-1/3 drams 

Divide in 8 bottles; give a feeding every three hours during the day and night, if 
the baby is awake. 

For an infant two weeks old (1:4). 

Top milk 4 ounces Proteins 0.6 

Lime water 1/2 ounce Sugar 6.00 

Water 15-1/2 ounces Fat 1.20 

Sugar 2/3 ounce 

Divide in 8 bottles; give a feeding every three hours during the day and night, if 
the baby is awake. 

For an infant one month old (1:2). 

Top milk 6-1/2 ounces Proteins 0.75 

Lime water 3/4 ounce Sugar 6.00 

Water 17-1/2 ounces Fat 1.50 

Sugar 3/4 ounce 

Divide in 7 bottles; give a feeding every three hours during the day and night, if 
the baby is awake. 

For an infant two months old (1:3). 

Top milk 10 ounces Froteins 1.00 

Lime water 1-1/4 ounces Sugar 6.00 

Water 19 ounces Fat 2.00 

Sugar.. 7/8 ounce 

Divide in 7 bottles; give a feeding every three hours during the day, and once 
during the night if the baby is awake. 



54 DISEASES OF CHILDREN 

For an infant three months old (1:1). 

Whole milk 18 ounces Proteins 1.50 

Lime water 2-1/4 ounces Sugar 6.00 

Barley water 16 ounces Fat 2.00 

Sugar 2/3 ounce 

Divide in 7 bottles; give a feeding every three hours during the day, and once 
during the night if the baby is awake. 

For an infant five months old (2:1). 

Whole milk 26 ounces Proteins 2.00 

Lime water 3-1/4 ounces Sugar 6.00 

Barley water 10 ounces Fat 2.60 

Sugar 1/2 ounce 

Divide in 6 bottles; give a feeding every three hours. 

For an infant seven months old (2:1). 

Whole milk 32 ounces Proteins 2.25 

Lime water 4 ounces Sugar 6.00 

Barley water ^T^ ounces Fat 3.00 

Sugar 1/2 ounce 

Divide in 6 bottles; give a feeding every three hours. 

For an infant nine months old (4:1). 

Whole milk 34 ounces Proteins 2.45 

Lime water 4-1/2 ounces Sugar 6.00 

Barley water (concentrated) ... 4 ounces Fat 3.25 

Sugar 1/3 ounce 

Divide in 5 bottles; give a feeding every four hours. 

For an infant eleven months old (5:1). 

Whole milk 37-1/2 ounces Proteins 2.50 

Lime water 4-3/4 ounces Sugar 6.00 

Barley water (concentrated) ... 3 ounces Fat r 3.50 

Sugar 1/4 ounce 

Divide in 5 bottles; give a feeding every four hours. 

For infants over a year, give undiluted whole milk. 

The method of home modification of milk here described, while 
not very exact, is based upon clinical experience, and has the further 
advantage over many other methods in vogue in that it does not re- 
quire the knowledge of higher mathematics for its calculation. In- 
fant feeding by calories, while very ingenious, is hardly applicable 
in the feeding of infants under three or even six months of age, since 
it provides amounts of fat or protein often entirely beyond the in- 
fantile digestive capacity. According to Heubner* an infant requires 
a daily ration of about 45 calories for every pound of its weight dur- 
ing the first quarter of a year ; 40 calories during the second quarter ; 
35 during the third ; and 30 during the fourth quarter. Fifteen grains 
(1 gram) of protein or carbohydrates furnish 4.1 calories and 15 grains 
of fat, 9.3 calories ; or 1 ounce of whole milk, 20 calories. Taking for 



'Both Heubner's and Budin's suggestions work well in breast feeding. 




PLATE II 

Formed Alkaline Stools 

A marked example of the formed, alkaline stools, consisting largely of soaps, 
sometimes found in feeding with cow 's milk, without excess of fat ; or with ' l pro- 
tein" milk. They are associated with increased putrefaction but diminished fer- 
mentation in the intestinal canal. 

(Courtesy Dr. Hector Charles Cameron.) 



PREVENTION AND CONTROL OF DISEASE 55 

example an infant one month old, ordinarily weighing 8 pounds, it 
would require in twenty-four hours, 8 x 45 = 360 calories, i. e., either 
18 ounces of whole milk, which would be entirely too rich in casein 
for an infant of that age, or 4^ ounces of gravity cream greatly di- 
luted, which would be too rich in fat and too poor in protein and sugar. 
The same fault is to be found in Budin's method of giving daily an 
amount of milk equal to 10 per cent of the body weight of the baby. 

The keynote of successful artificial feeding is individualization, 
i. e., the selection of a food in proper proportions as to fat, sugar, and 
protein suitable for each individual baby's power of digestion and as- 
similation, and in sufficient quantities. The amount of food needed 
by the healthy infant is best judged by the capacity of the stomach*, 
subject, of course, to variations as to size, activity, etc. The question 
of the proportion of the food elements must be decided from time to 
time in each individual case, after considering the gain or loss in 
weight under the respective food, and watching the consistency, etc., 
of the bowel movements. 

Indications of Faulty Assimilation of the Food 

All disturbances of digestion, be they due to an excess of protein, 
sugar, or fat, have several symptoms in common, thus : Restlessness, 
flatulence, colic, loss in weight, frequent defecations and vomiting; 
in acute indigestion also moderate or high fever. To determine 
whether the digestion of fat, sugar, or protein is at fault, we have to 
examine the vomitus and feces. 

In fat digestion, the stools are either soft (containing soft curds) 
and oily in appearance or of a creamy consistence, or, especially in 
cases of long duration, gray or grayish yellow, hard and dry, forming 
the so-called "soap-stools." Sometimes the stools are watery, strongly 
acid, causing severe irritation of the buttocks. The vomitus is also 
strongly acid. The lips are often cherry-red in color. 

In sugar indigestion vomiting is less common than in fat indigestion, 
but if it does occur, the vomitus, like the feces, is acid in reaction and 
often presents the characteristic odors of lactic, acetic or succinic 
acid. The stools are usually thin, often mixed with mucus, light or 
dark green, and very irritating to the buttocks. In severe cases there 
may be high fever, with other symptoms of acute intoxication. 

Starch indigestion may give rise to loose, brown stools, mixed with 



*The following fairly represents the average capacity of the infantile stomach: At the 
end of the first week, 1 ounce ; the second week, 2 ounces ; first month, 3 ounces ; second month, 
4 ounces; fourth month, 5 ounces; sixth month, 6 ounces; eighth month, 7 ounces; tenth month, 
8 ounces; twelfth month, 9 ounces; fourteenth month, 10 ounces. 



56 DISEASES OF CHILDREN 

mucus, changing into blue color on addition of iodine. Infants fed 
exclusively on starch food slowly develop athrepsia. 

An excess of casein usually gives rise to large, often tough, curds in 
the vomitus and stools, neutral or slightly acid in reaction and free 
from any characteristic odor. In some cases the stools are loose, mu- 
cous, brown in color, and musty in odor. 

The management of the aforementioned digestive disturbances, in 
a way, is self-evident: we have to reduce temporarily the offending 
food element in the infant's diet, which must either be reduced in 
quantity or eliminated entirely. Skimmed milk and cereals should 
be given in fat indigestion: diluted skimmed milk or Eiweissmilch in 
carbohydrate indigestion; or condensed milk, well-diluted boiled milk, 
or weak mixtures of Eiweissmilch with the addition of malt dextrin in 
digestive disturbances due to an excess of protein. Of course, with dis- 
appearance of the symptoms the required fat, carbohydrate- and pro- 
tein-proportions of the food are gradually to be resumed. (See also 
"Dyspepsia" and "Acidosis.") 

Cow's Milk Substitutes 

Malt Soup. — Two ounces of wheat-flour are slowly and thoroughly 
mixed with one pint of milk, and strained through gauze. In a second 
vessel 3 ounces of thick malt are dissolved in a quart of warm water 
to which had been added 15 grains of carbonate of potassium.* Now 
both solutions are mixed together and heated very slowly up to a boil. 
As the children improve the water may gradually be reduced to a 
pint. Malt soup is often particularly beneficial in underfed, dyspep- 
tic and rachitic babies. If well tolerated it may be continued for sev- 
eral months. 

It is advisable, however, gradually to replace the malt soup by or- 
dinary milk mixtures, and other foods (p. 60). 

Condensed Milk. — Where the principal difficulty consists in incapac- 
ity to digest cow's milk casein, condensed milkf Avill be found to act 
kindly, since the consistency of the coagulum of condensed-milk casein 
formed in the infantile stomach greatly resembles that of human 
milk. It has also the advantages of being inexpensive and not as 
readily subject to contamination as ordinary cow's milk. However, 
containing as it does about 51 per cent of sugar, and requiring eight 
to ten times dilution to approximate the sugar content of human milk, 

*Malt soup extracts are now procurable in every reliable pharmacy. 
f Approximate Composition of Canned Condensed Milk: 

Protein Sugar Fat Salts Water 

8.00 51.00 _ 7 1.50 32.00 

Fresh condensed milk contains only 10 per cent of sugar. 



PREVENTION AND CONTROL OF DISEASE 57 

the simultaneous reduction (by dilution) of the fat and proteid con- 
tents to about 1 per cent and l 1 /^ per cent respectively, renders con- 
densed milk too poor in quality to serve as an ideal infant food. In- 
deed, it is usually found that infants over three months, fed on di- 
luted condensed milk, soon contract rachitis. Nevertheless, as a tem- 
porary food, especially during the summer months or on a long journey, 
it is invaluable. As already suggested, condensed milk should be ad- 
ministered in quantities appropriate for the infant's age, in dilution 
with from eight to ten or even twelve parts of plain or cereal water. 
The deficiency of fat may be supplemented by the addition of cream. 
Whey. — "Where the digestive capacity of casein is greatly at fault, 
we may temporarily resort to whey feeding. Whey is obtained by 
adding to a pint of fresh warm (100° F.) milk, two teaspoonfuls of es- 
sence of pepsin. After it stiffens, beat up the curd with a fork and strain 
through a few layers of gauze, so as to withhold the coagulated casein. 
The decanted liquid contains approximately: 

Protein Sugar Fat 

Lactalbumin 0.9% 4.5% 0.5% 

Casein 0.3% 

By adding a little cream to overcome its deficiency and employing a 
cereal diluent instead of plain water, the whey mixture is amply nu- 
tritious to sustain an infant's vitality for several weeks. 

Buttermilk* — This is prepared by thoroughly mixing, in a suitable 
agate vessel, one quart of fresh, rich milk, with a pint or less of water, 
a pinch of salt, and the pure lactic acid culture (any one of the pure 
mercantile lactic bacilli tablets answers the purpose). The vessel is 
covered with a thin cloth and allowed to stand in the room (70° to 80° 
F.) for from eighteen to twenty-four hours. It is now placed on ice 
until needed. For infant feeding we add to every quart of buttermilk 
a flat tablespconful of wheat-flour and two tablespoonfuls of cane sugar 
and allow the mixture to boil over a low fire, for two to three minutes, 
with constant stirring. The food is now poured, in quantities varying 
with the age of the patient, into sterilized bottles, properly corked, 
and placed on ice until used. The mixture is indicated especially 
in cases requiring a high percentage of protein and a low percentage of 
fat, e. g., gastroenteritis and fat indigestion. 

Eiweissmilch (Albumin-, Protein-, or Casein- Milk). — This food, orig- 
inally recommended by H. Finkelstein and L. Meyer, is gradually be- 
ing accepted by the profession as an ideal food in the management of 
fermentative dyspepsia and nutritional disturbances from intolerance of 



■"Composition: Water: 90.27; protein: 4.06; fat: 0.93; sugar: 3.73; salts: 0.67. 



58 DISEASES OF CHILDREN 

milk. It consists of 2.50 per cent of fat, 1.5 per cent of sugar, 3 per 
cent of protein, and 0.50 per cent of salts, and is prepared as follows: 
One liter of warm milk is treated with 15 grams of essence of pepsin, 
and allowed to stand in a water bath at 107.6° F., until a curd is formed. 
This mass is poured into a linen bag and allowed to filter for about half 
an hour, and while gradually adding half a liter of water the curd is 
pressed through a fine sieve two or three times by means of a wooden 
spoon. To this milk-like mixture we next add half a liter of butter- 
milk. Finkelstein and Meyer were prompted to suggest the Eiweiss- 
milch after establishing the facts that nontoxic fermentative dyspepsia is 
due principally to abnormal fermentation of the carbohydrates (not the 
casein ! ) of the infant food, and that fat forms a disturbing element 
only when preceded by sugar fermentation. Albumin milk should be 
given in quantities of about iy 2 to 2 ounces every three or four hours. 
In very young infants it may at first be diluted with an equal quantity 
of plain water and later barley water. As the patient improves, it is 
advisable to increase the amount of the Eiweissmilch and to strengthen it 
also by the addition of 1 per cent of maltose, or malt dextrin. After 
full recovery from the disease, Eiweissmilch feeding is gradually dis- 
continued. Protein milk is now obtainable in powder form. 

Dry Milk. — A number of clinicians have for some time been advocating 
the use of dry milk in infant feeding, especially in cases of difficult diges- 
tion and on long journeys. The approximate composition of whole dry 
milk is as follows : Fat 25 per cent, lactose 40 per cent, protein 28 per 
cent, salts 7 per cent and moisture 5 per cent. It is usually adminis- 
tered in 1 to 3 or 1 to 2 dilutions, with plain, boiled, or cereal water, in 
the same manner as fluid milk. Its prolonged use is contraindicated, 
even though some pediatrists claim that dry milk is not productive of 
scurvy or rachitis. 

Mode of Manufacture. — The principal processes by which dried milk 
is made today are briefly as follows : 

A. Milk is fed in a thin stream over two steam-heated cylinders or 
drums, about one-eighth of an inch apart and revolving in opposite di- 
rections. The milk exposed to the heat of the cylinders dries as a thin 
film and comes off the revolving cylinder as a sheet, which is easily 
crushed into a fine powder. The cylinders, which are some sixty inches 
long and 24 inches in diameter, are charged with steam under two or 
three atmospheres of pressure causing the heating surfaces to have a 
temperature of about 250 to 280° F. This process, known as the Just 
patent in the United States and as the Just-Hatmaker patent in England, 
is said to be the invention of J. E. Hatmaker, of London. 



PREVENTION AND CONTROL OF DISEASE 59 

B. The milk is first pasteurized and then condensed in the vacuum 
pan at a low temperature (130° F.) to about one-fourth of its bulk. 
This condensed product is forced under high pressure through 
minute openings in a metal disk into a hot-air chamber. The atomized 
liquid surrounded by a current of hot air instantly dries and falls to the 
bottom of the chamber as a snowy powder, the moisture rising as a cloud 
of steam. The mixture of the liquid and air in the evaporating chamber 
is stated to be about 180° F. This method was originally developed in 
France and is called there and in England the Bevenot de Neveu process. 
In this country it is known as the Merrill-Gere process. 

C. A third method of making dried milk, by reducing it to approxi- 
mate dryness in a vacuum pan equipped with a mechanical stirrer, is 
also used in this country. It has the advantage of exposing the milk to 
a low though prolonged temperature. 

Proprietary Milk Modifiers and Milk Foods. — We distinguish two 
kinds of proprietary foods — milk modifiers and so-called milk foods. 
Neither of them contain a sufficient amount of nutrient elements to sup- 
ply the needs of the baby for life and growth for any length of time ; 
they are useful, however, in digestive disturbances and "milk idiosyn- 
crasy," and to bridge over an acute siege of sickness. The mercantile 
milk modifiers furnish soluble carbohydrates, free starch, or predigested 
proteids in small quantities, and thus save the trouble of home prepara- 
tion of suitable diluents. Their prolonged exclusive use is frequently 
followed by scurvy and rickets. 

Peptonized Milk. — The use of peptonized milk is nowadays limited 
chiefly to feeding of children of very low vitality, in whom the powers 
of digestion are in abeyance, e. g., high fever, coma (administered in 
the form of nutrient enemata, or by gavage), pylorus stenosis, etc. 

Mode of Preparation. — Mix in a quart bottle one pint of fresh milk 
with 4 ounces of cold water containing 5 grains of pancreatic extract 
and 15 grains of sodium bicarbonate, or the contents of one of Fair- 
child's peptonizing tubes. Place the bottle in a pot of hot water and 
maintain its temperature at about 115° F., either for about twenty 
minutes ("partial" peptonization) or two hours ("complete" peptoni- 
zation). Shake the bottle from time to time. When the mixture is 
ready, give it, either pure or diluted, in quantities suitable for the age 
of the child. Keep it on ice until used. 

Weaning the Baby and Its Feeding Thereafter 

Ordinarily it is not advisable to nurse an infant beyond ten or 
eleven months old. As exceptions to this rule, we may mention the 
very hot summer months, acute diseases, difficult teething, etc., when 
a complete change in feeding is prone to prove hazardous to the 



60 DISEASES OF CHILDREN 

child's health. It is preferable to wean a baby gradually, by substi- 
tuting bottle- for breast-feeding's, and to continue partially to nurse 
it, until the infant lias learned to submit to the inevitable, and thrives 
well on the new food. 

Feeding of Infants Over Seven Months Old. — When the normal infant 
reaches the age of seven months or thereabouts, nature announces the 
urgency of a change in the dietary — from liquid to solid — by has- 
tening the eruption of the lower and upper incisors. At this age, 
also, salivary digestion is fully established, so that an allowance, 
once or twice a clay, of a crust of stale or toasted bread, or zwie- 
back, certainly can do no harm. As at this period of life the ten- 
dency to rickets is very pronounced, the dietary should be grad- 
ually improved upon by the addition of small quantities of cereals, 
a teaspoonful or more of fresh, soft-boiled egg, strained chicken, 
mutton, or beef soup, with fresh vegetables (e. g., carrots, potatoes, etc.), 
orange or pineapple juice, baked potato with some sweet cream or but- 
ter ; and later (at about a year,) bread and butter, milk custards, cocoa, 
and occasionally finely scraped beef or chicken. 

Of course the transition from an exclusive milk diet to a more or 
less mixed diet must be very slow and gradual. The effect of the 
change should be watched from day to day and week to week, al- 
ways bearing in mind that milk is the ideal food for the infant and 
indispensable to the child up to the period of second dentition. 

This fact should be strongly impressed upon those in charge of the 
child, as only too often, with the allowance of a semisolid diet, milk 
is crowded out entirely by an oversupply of thin soups, indigestible, 
proprietary "breakfast foods," and all sorts of sweets and fruit of 
poor quality, which sooner or later upset the child's digestive powers 
and arrest its growth and development — doing just the opposite of 
what the change of diet was intended for. 

With the change in the diet it is also frequently observed that the 
infants refuse to drink milk. Inquiry into the cause usually reveals 
the fact that upon the advice of some artistically inclined neighbor — 
who thinks that the bottle effaces the child's "beauty lines" — and 
more generally upon the recommendation of the family physician, the 
child is forced to part with its bottle and nipple — its dear and faith- 
ful companions for the many months past. Y\ T hy milk bottles are to 
be looked upon as an abomination for children over a year or so and 
as a salvation for those under this age, is to me a mystery. The mere 
facts that if given in a bottle, large quantities of milk are enjoyed by 
children up to four or five years of age ; that if taken through a nipple, 
milk enters the stomach slowly, and, hence, is more easily digested, and 
finally, that during sickness milk (as well as water) is best administered 



PREVENTION AND CONTROL OF DISEASE 61 

through a bottle, are ample justifications for the encouragement rather 
than the prohibition of the use of the bottle — provided, of course, that 
the bottles, as well as the nipples, are kept scrupulously clean; are 
sterilized, if you please. 

The additional articles of food should be given at definite intervals, 
preferably together with the milk feeding. Thus, for example, with the 
ten o'clock bottle the child should receive the soft-boiled or poached 
egg and crackers; at two o'clock the meat broth and potato; at six 
o'clock, some cereal and bread and butter. Orange or pineapple juice 
may also be given between meals. The child should be taught to ap- 
preciate that to get other foodstuffs it must drink its allowance of milk. 

Diet for Child 

From 18th to 24th Month 
Breakfast 

1. Juice of 1 sweet orange 

or 
Pulp of 6 stewed prunes 

or 
Pineapple juice (fresh or bottled) 1 ounce. 

2. Dessert : apple sauce, prune pulp, with stale lady-fingers or graham wafers. 

top milk (top 16 ounces) sweetened or salted. A glass of milk, bread and 

butter. 

Note: If constipated give the fruits half -hour before breakfast with water; 

if not, they may be given during the forenoon. 

Eaw fruit juice must be given either half -hour before or half -hour after milk. 

Forenoon 
A glass of milk with two toasted biscuits or zwieback or graham crackers. 

Dinner 

1. Broth or soup made of beef, mutton, or chicken, and thickened with peas, farina, 

sago or rice 

or 
Beef juice with stale bread crumbs; or clear vegetable soup with yolk of egg 

or 
Egg soft boiled, with bread crumbs, or the egg poached, with a glass of milk. 

2. Dessert : apple sauce, prune pulp, with stale lady-fingers or graham wafers 

or 
Plain puddings: rice, bread, tapioca, blanc-mange, junket or baked custard, bread 
and butter. 

3 p. m. 
A cup of milk with biscuits. 

Supper 
An egg, glass of milk, zwieback and custard, or stewed fruit. 
Total milk in 24 hours, 1 quart. 

Diet for Child 

From Two to Three Years 

Brealcfa-st 
1. Juice of 1 sweet orange 
or 
P'ulp of 6 stewed prunes 

or 
1 ounce pineapple juice C fresh or bottled) 

or 
Apple sauce (warm). 



62 



DISEASES OF CHILDREN 



2. A cereal such as oatmeal, farina, cream of wheat, hominy or rice, slightly sweet- 

ened, or salted, as preferred, with the addition of top milk, 
or 
A soft boiled or poached egg with stale bread or toast. 

3. A glass of milk. 

Note: If constipated give the fruits y 2 hour before breakfast with water; if not, 
they may be given during the forenoon. 
Milk and raw fruit juice must not be given at same meal. 

Dinner 

1. Broth or soup made of chicken, mutton or beef, thickened with arrowroot, split 

peas, rice, or with addition of the yolk of an egg or toast squares. 

2. Scraped beef or white meat of chicken or broiled fish (small amount) bread and 

butter 
or 
Mashed or baked potatoes with fresh peas or spinach or carrots. 

3. Dessert: apple sauce, baked apple, rice pudding, junket or custard. 

3 p. m. 
A cup of milk with biscuits. 

Supper 

1. A cereal or egg with stale bread or toast and butter. Cup of cocoa. 

or 
Bread and butter and milk, or bread and butter and cocoa, or bread and custard. 

2. Stewed fruit. 

Feeding of Children from Four to Six Years Old. — The dietary of 
children over four years old is practically identical with that just men- 
tioned, except that the quantity of the food should be more liberal, the 
fruit may be given raw, and that the between-meals milk allowance 
should be dispensed with. Occasionally the child may receive home- 
made cake, a little ice cream and other condiments of good quality. All 
these foodstuffs, however, should be given with regular meals. 

Average Composition of Common American Food Products* 



Food materials (as 
purchased). 



Sirloin steak 

Eound steak 

Veal, leg cutlets . . . 

Veal, breast 

Mutton, leg, hind . . 
Mutton, loin chops. 

Lamb, breast 

Pork, loin chops. . , 

Ham, smoked 

Bacon, smoked .... 

Soup, beef 

Soup, tomato 



p. c. 

12.8 

7.2 

3.4 

21.3 

18.4 

16.0 

19.1 

19.7 

13.6 

7.7 



p. c. 

54.0 
60.7 
68.3 
52.0 
51.2 
42'.0 
45.5 
41.8 
34.8 
17.4 
92.9 
90.0 



p. c. 

16.5 

19.0 

20.1 

15.4 

15.1 

13.5 

15.4 

13.4 

14.2 

9.1 

4.4 

1.8 



p. c. 

16.1 
12.8 

7.5 
11.0 
14.7 
28.3 
19.1 
24.2 
33.4 
62.2 
.4 

1.1 



i oJ 
O U 



p. C. 



1.1 

5.6 



p. c. 

.9 

1.0 
1.0 



J 



4.2 
4.1 
1.2 
1.5 



r3 

O 
ft 



Calo- 
ries. 

975 

890 

695 

745 

890 

1,415 

1,075 

1,245 

1,635 

2,715 

120 

185 



After Nelson's Perpetual Loose L,eaf Encyclopaedia. 



PREVENTION AND CONTROL OF DISEASE 



63 



Average Composition of Common American Food Products — Cont'd 



Food materials (i 
purchased). 



Chicken, broilers 

Fowls 

Cod, dressed 

Mackerel, whole 

Salmon, canned 

Oysters, ' ' solids " 

Lobsters 

Hens' eggs 

Butter 

Whole milk 

Buttermilk 

Cream 

Cheese, full cream 

Entire-wheat flour 

Flour, white 

Corn meal 

Oat breakfast food. . . 

Bice 

Tapioca 

Bread, white 

Bread, Graham 

Cake 

Soda crackers 

Molasses 

Candy, plain 

Sugar, granulated 

Beans, dried 

Cabbage 

Celery 

Onions 

Peas, shelled 

Potatoes, white 

Potatoes, sweet 

Tomatoes 

Apples, fresh 

Apples, dried 

Bananas 

Grapes 

Muskmelons 

Oranges 

Strawberries 

Watermelons 

Raisins 

Chestnuts 

Peanuts 

Walnuts, English 

Chocolate 

Cocoa, powdered 

Cereal coffee, infusion 
(1 part boiled in 20 
parts water) 



tf 



p. c. 



41.6 
25.9 
29.9 

44.7 



61.7 
all.2 



15.0 
20.0 
10.0 



20.0 
20.0 



25.0 



35.0 
25.0 
50.0 
27.0 
5.0 
59.4 
10.0 
24.0 
24.5 
58.1 



p. c. 



43.7 
47.1 
58.5 
40.4 
63.5 
88.3 
30.7 
65.5 
11.0 
87.0 
91.0 
74.0 
34.2 
11.4 
12.0 
12.5 

7.7 
12.3 
11.4 
35.3 
35.7 
19.9 

5.9 



12.6 

77.7 

75.6 

78.9 

74.6 

62.6 

55.2 

94.3 

63.3 

28.1 

48.9 

58.0 

44.8 

63.4 

85.9 

37.5 

13.1 

4.5 

6.9 

1.0 

5.9 

4.6 



98.2 



p. c. 



12.8 

13.7 

11.1 

10.2 

21.8 

6.0 

5.9 

13.1 

1.0 

3.3 

3.0 

2.5 

25.9 

13.8 

11.4 

9.2 

16.7 

8.0 

.4 

9.2 

8.9 

6.3 

9.8 



22.5 

1.4 

.9 

1.4 

7.0 

1.8 

1.4 

.9 

.3 

1.6 

.8 

1.0 

.3 

.6 

.9 

.2 

2.3 

8.1 

19.5 

6.9 

12.9 

21.6 



p. c. 



1.4 
12.3 

.2 

4.2 

12.1 

1.3 

.7 

9.3 

85.0 

4.0 

.5 

18.6 

33.7 

1.9 

1.0 

1.9 

7.3 

.3 

.1 

1.3 

1.8 

9.0 

9.1 



.1 
.3 
.5 
.1 
.6 
.4 
.3 

2.2 
.4 

1.2 

.1 
.6 
.1 

3.0 

5.3 

29.1 

26.6 

48.7 
28.9 



p. c. 



3.3 
.2 



5.0 

4.8 

4.5 

2.4 

71.9 

75.1 

75.4 

66.2 

79.0 

88.0 

53.1 

52.1 

63.3 

73.1 

70.0 

96.0 

100.0 

59.6 

4.8 

2.6 

8.9 

16.9 

14.7 

21.9 

3.9 

10.8 

66.1 

14.3 

14.4 

4.6 

8.5 

7.0 

2.7 

68.5 

56.4 

18.5 

6.8 

30.3 

37.7 



1.4 



p. c. 



.7 

.7 

.8 

.7 

2.6 

1.1 

.8 

0.9 

3.0 

.7 

.7 

.5 

3.8 

1.0 

.5 

1.0 

2.1 

.4 

.1 

1.1 

1.5 

1.5 

2.1 



3.5 

.9 

.8 

.5 

1.0 

.8 

.9 

.5 

.3 

2.0 

.6 

.4 

.3 

„4 

.6 

.1 

3.1 

1.7 

1.5 

.6 

2.2 

7.2 



Calo- 
ries. 
~305 
765 
220 
370 
915 
225 
145 
635 
3,410 
310 
160 
865 
1,885 
1,650 
1,635 
1,635 
1,800 
1,620 
1,650 
1,200 
1,195 
1,630 
1,875 
1,225 
1,680 
1,750 
1,520 
115 
65 
190 
440 
295 
440 
100 
190 
1,185 
260 
295 
80 
150 
150 
50 
1,265 
1,385 
1,775 
1,250 
2,625 
2,160 



30 



i 



G4 DISEASES OF CHILDREN 

II. HYGIENE AND SANITATION 

Next to suitable nutrition, hygiene and sanitation play the most im- 
portant role in the preservation of good health. It is within the 
province of the physician's duties to formulate, to those intrusted 
with the care of the child, rules and regulations as to its cleanliness 
and comfort, mode of clothing, time for sleeping, airing, bathing, 
rest and exercise, both during health and disease. Without the advice 
and supervision of the physician, the nurse or mother is only too apt 
either to overdo or underdo, i. e., in both events do irreparable damage 
to the health and welfare of the child. Unfortunately blind credulity, 
stupid mysticism and absurd fatalism still reign supreme, the great 
strides in science and adventure notwithstanding. 

General Care of the Newborn and Older Children 

The Newborn. — Immediately after birth the infant instinctively, by 
its shrill cry, announces its demand for protection against the sharp 
change of atmosphere and surroundings. Therefore, after dressing its 
navel (p. 221), washing its eyes and mouth with a saturated boric acid 
solution, and instillation into each eye of one drop of a 2 per cent solu- 
tion of nitrate of silver, the baby should be wrapped in a warm woolen 
blanket and placed in a warm, darkened, but airy, quiet room, and left to 
rest for a few hours. It should then be sponged off with warm soap 
water, dressed, given a little clean water, and, the condition of the mother 
permitting, put to the breast (p. 44). Whenever possible, the child's crib 
should be kept in a room apart from that of the mother, so that 
the latter is not disturbed by the possible uneasiness experienced by 
the baby. As lactation is usually not fully established before the 
third or fourth day after labor, the infant should, in the meantime, 
several times daily receive a few teaspoonfuls of plain or slightly 
sweetened warm water or of a mild carminative, such as fennel-seed 
tea, to satisfy its thirst and hunger. 

Sleep. — The normal newly born baby sleeps practically all the time 
except the brief periods occupied with nursing, diapering, and dress- 
ing. If the baby is well developed and strong, it should be left to 
sleep until it wakes up of its own accord from hunger; if delicate, it 
should be aroused every two or three hours during the day, and once 
at night, made to cry a little to help to expand its lungs and put to the 
breast for from ten to twenty minutes. At six weeks the infant needs 
twenty hours of sleep ; at three months, eighteen ; at one year, sixteen, 
and from two to four years, fourteen hours of sleep. All children 
should get accustomed to sleep uninterruptedly (except for one nurs- 



PREVENTION AND CONTROL OF DISEASE 65 

ing in the middle of the night in early infancy), from seven in the 
evening until seven o'clock in the morning, and one hour each some 
time between seven and twelve o'clock in the forenoon and two and 
seven in the afternoon. 

Sleeplessness in the infant is ordinarily due to intestinal colic or 
other pain, discomfort from soiled diapers or faulty dressing (over- 
heating by superabundance of clothes, etc.), noise in the room, lack 
of ventilation, bad habits, such as rocking, or keeping an empty nipple 
in the mouth, etc. Repeated waking is frequently due to over- or 
under-feeding. 

Bathing. — In view of possible local or systemic infection (p. 219) 
through the umbilical rest, and the advisability of keeping the latter 
perfectly dry, the full tub bath should be withheld until the navel 
has completely healed. The same applies for circumcision wounds. 
In the meantime the infant should receive at least one sponge bath a 
day, to be given as gently as possible, since the infantile skin is very 
delicate, very apt to be abraded on rough handling, and readily be- 
comes subject to divers skin affections. 

In the absence of the aforementioned or other contraindications, 
every child, in addition to local cleansing as frequently as necessity 
arises, should receive a tub bath once a day, preferably at bedtime. 
The water used should be free from visible impurities, and obtained 
from sources inaccessible to pollution. The temperature of the 
water should range between 95° F. and 98° F., the latter for infants 
under six months, and cooler water for older ones. Fat babies toler- 
ate much lower temperatures, but I see no special benefit to be de- 
rived from the use of bath water under 95° F. unless it be in the open 
sea or ocean (which is permissible in children over three years of age), 
where the saline ingredients and forceful current exert a stimulat- 
ing, refreshing effect upon the system and thus counteract the 
depression produced by the sudden lowering of the body tempera- 
ture. If cool bathing is desirable, it is better to place the child 
in warm water and either gradually cool off the water while the child 
is in the tub or use a cold shower. The bath should be followed -by 
thorough drying of the body and gentle friction. Care should be ex- 
ercised in the selection of pure, nonirritating bathing soap, lest its 
irritating ingredients may prove a source of annoying skin eruptions. 
For the same reason and, furthermore, owing to the fact that they 
are apt to harbor dirt and disease, the use of sponges is to be depre- 
cated. 

Clothing. — Infants should be clothed warmly and simply, free from 
fancy frocks and frills, strings and bows, that embarrass free motion, 



66 DISEASES OF CHILDREN 

breathing, sleeping and eating. The underwear should be made of silk 
or thin flannel. The abdomen should be protected against being chilled 
by a flannel band. The consistency of the outer clothing should vary 
with the changes of the weather and season of the year. The feet 
of infants should at all times be kept warm, if necessary, by means 
of a hot-water bag. The night clothes should be loose and warm, 
and consist, in addition to a small silk or flannel shirt, Canton flannel 
or stockinet diaper and the belly-band, of a nightshirt in the form 
of a "bag" that buttons around the neck and can be closed at the 
feet by means of drawstrings. In this manner the unnecessary pil- 
ing up of blankets, to keep the baby from uncovering, can be advanta- 
geously dispensed with. 

Older children should gradually get accustomed to light clothes — 
linen or silk undergarment, linen or woolen suit or dress, and for the 
winter a warm top coat and cap — but no collars or neck mufflers. A 
woolen union suit with feet for the night. Special attention should 
be paid to the selection of shoes. They should comfortably fit the 
feet and allow spreading of the toes. The stockings should be fas- 
tened to the drawers, as garters are apt to interfere with the blood 
circulation of the lower extremities. The corset should be prohibited 
in girls under fourteen. 

Airing. — Fresh, pure air is the panacea for good health, the cure of 
all bodily ills. Thus far it is nonassessable, nontaxable, and hence 
should be inhaled ad libitum — while this freedom lasts. Weather per- 
mitting, it should be inhaled out of doors, otherwise indoors; — in prop- 
erly ventilated rooms. The newborn should be taken outdoors in the 
summer when it is two weeks old, in the spring and fall at one month 
and in the winter at two months of age or later. It should be suitably 
dressed and protected from undue exposure to the sun and wind and 
severe cold. It is foolhardy to expose an infant to marked atmos- 
pheric changes without proper shelter, merely for the purpose of 
"hardening" it. Its first airing should last from fifteen to thirty 
minutes, and as it grows older the airing time should be lengthened, 
so that, weather permitting, the child may live outdoors the greater 
part of the day from sunrise until sunset. Slight rain or snow forms 
no hindrance to taking the baby outdoors, although in such weather 
delicate babies do better if aired indoors, in front of open windows 
and dressed as for outdoors. 

Exercise. — A healthy infant, if not immobilized by burdensome 
clothes, begins to take physical exercise soon after birth. It kicks, 
moves its arms and head and exercises its thoracic muscles while cry- 
ing lustily, especially when feeding time approaches. It should be 



PREVENTION AND CONTROL OP DISEASE 67 

picked up in the arms at every nursing to insure change of position. 
At about four months of age the baby is able to hold its head erect; 
it may then be gradually trained to sit upright upon the arm of the 
nurse,, its back and head well supported. As it reaches the age of 
seven or eight months, the infant may be seated alone in a baby-chair 
supported with pillows at the back and sides. When it shows an 
effort to creep, it may be placed upon the floor, which should be well 
covered by thick carpet or a blanket, preferably within a small porta- 
ble "creeping pen," and allowed to roam about for half an hour 
at a time once or twice a day. Less freedom should be granted an 
infant in its first attempts to stand or walk. These practices should 
not be encouraged in babies under one year of age, nor in older chil- 
dren who show a tendency to bony curvatures and rickets. In the 
beginning they should not be allowed to stand or walk, especially 
if unsupported, for more than a few minutes at a time. But, as they 
grow older and stronger, they are gradually permitted to enjoy shorter 
or longer outdoor walks and to romp merrily, giving vent to that 
characteristic boundless joyousness of early childhood which is bless- 
edly ignorant of the pangs and pains of later life. 

Older children, like infants, should spend the greater portion of 
the day outdoors in parks and playgrounds and engage in amusing 
games and light calisthenics which will keep them from harm and 
mischief. It is opportune on this occasion to emphasize the danger 
of overindulgence in the practice of gymnastics, especially in children 
of school age — a period of life which is coincident with prevalence of 
communicable diseases and their grave sequela?, particularly cardiac 
involvement. 

It is the duty of the physician to impress upon those under his 
care that while moderate exercise — especially walking, skating and 
horse-back riding ; the daily use, for about fifteen minutes at a time, 
of light wooden dumb-bells, light clubs or wands ; the practice of breath- 
ing (p. 439), of swinging of the body from a swinging bar or rings 
and straps, — will do much for the development of delicate and narrow 
chests and to prevent and straighten curvatures of the spine, stooping 
of the shoulders, and the like (and should be encouraged), violent 
sports, like racing, rough baseball- and football-playing, leaping, .pro- 
longed swimming and similar severe exercises indulged in to excess, 
will sooner or later lead to cardiac hypertrophy with its consequences. 

Nursery. — As infants and older children spend about two-thirds or 
more of their time of life in the nursery, provisions must be made that 
the room is spacious and airy, dry and sunny, that its air is fresh and 
pure, free from obnoxious odors, gases, dust and smoke. To thrive 



68 DISEASES OF CHILDREN 

well an infant requires about 1000 cubic feet of air space. The room 
should not be crowded with dust gatherers, *". e., overabundance of fur- 
niture, toys, heavy hangings, carpets, rugs, pictures, etc. The tem- 
perature of the room should be about 70° F. during the day and about 
65° F. during the night. Whenever possible, it should be heated from 
an open fireplace or hot-air furnace. Steam heat or gas often vitiates 
the air. To insure proper ventilation, it is advisable to keep the win- 
dows more or less open from top and bottom most of the time unless the 
outdoor temperature is below 35° F. The windows and doors should 
be widely opened while the child is outdoors, otherwise ventilation should 
be accomplished with the doors closed to avoid draughts. For the latter 
purpose one of the many ventilating devices on the market will prove 
very serviceable. 

Financial circumstances permitting, every child should have a sep- 
arate room, if possible, situated one floor above the ground. Of course, 
this is rarely attainable in the dingy apartments of overcrowded cities. 
Physicians should insist, however, on every child having a separate bed 
in order to minimize the danger of transmitting communicable diseases 
from the sick to the healthy child. 

The Sick-Boom. — The hygienic suggestions just made in reference 
to the nursery apply with greater force to the sick-room. If possible, 
the latter should be situated on a different floor from the living apart- 
ments. From a sanitary as well as economic point of view it is essen- 
tial to have the sick-room cleared of curtains, tapestries, superfluous 
furniture, carpets, etc., so as to facilitate keeping the room perfectly 
clean, and to prevent pathogenic germs becoming firmly imbedded in 
those articles. The floor and furniture of the sick-room should be wiped 
off with a damp cloth instead of dusted or swept. 

An anteroom is a useful addition to a sick-room especially when the 
patient is suffering from a communicable affection, as it enables the 
nurse to disinfect the dishes, soiled bedclothes, linen, etc., and to pre- 
pare some of the patient's food. 

When the isolation-period of the patient is over, the sickroom, ante- 
room and their contents must undergo very thorough cleaning and dis- 
infection. 

Quarantine and Disinfection. — In order to prevent spreading of com- 
municable diseases from one individual to another, we have to resort 
principally to the following prophylactic measures: 

1. Isolation of the patient. 

2. Disinfection of the patient's excretions, fomites, etc., coming in 
contact with the pathogenic microorganisms. 



PREVENTION AND CONTROL OF DISEASE 69 

3. Exclusion of visitors and domestic animals, such as cats and dogs, 
and destruction of other germ carriers, e. g., mosquitoes, flies and fleas. 

1. Isolation of the Patient. — This is the most essential and efficient 
mode of prevention of transmission of disease. The isolation to be 
effective must begin early and be complete. In hospitals and asylums 
every child should be isolated in an observation ward for at least three 
days before being permitted to mingle with the other inmates ; in pri- 
vate families isolation should be enforced with the earliest appearance 
of tangible symptoms of the specific affection. As those coming in 
close contact with the patient are apt to carry the disease from the 
sick to the well, it is imperative to isolate the nurse together with the 
patient and to forbid any member of the family to stay around the 
sick-room or make herself generally useful, unless on entering the 
sick-room she dons a clean gown and cap, and before leaving it washes 
her hands and forearms with soap and water and removes the gown 
and cap. These latter rules should apply also to the physician. 

In a private dwelling, and especially in houses where a room is re- 
served for the sick, perfect isolation can readily be insured. In 
crowded tenement rooms, however, with people in poor circumstances, 
all attempts at isolation almost invariably fail, and where the spread- 
ing of a grave, epidemic affection is concerned (e. g., smallpox, cerebro- 
spinal meningitis), should not at all be attempted. In such cases 
it is best to remove the patient to a hospital for contagious diseases. 

The period of isolation varies, of course, with different diseases and 
the degree of severity. The following suggestions will meet the ordi- 
nary requirements as to the period of isolation and the principal mode 
of prophylaxis: 

In typhoid fever, while the disease lasts. (Disinfection of excreta; 
protection against flies, fleas, lice, etc.) 

In typhus fever, while the disease lasts. (Same as in typhoid.) 

In miliary tuberculosis, while the disease lasts. (Disinfection of ex- 
creta.) 

In epidemic cerebrospinal meningitis and poliomyelitis, while the 
disease lasts. (Disinfection of discharges.) 

In yellow fever, while the disease lasts. (Destruction of mosquitoes.) 

In relapsing fever, while the disease lasts. (Destruction of insects.) 

In influenza, pneumonia and pulmonary tuberculosis, while the dis- 
eases last. (Disinfection of discharges.) 

In bubonic plague, about one week after termination of the disease. 
(Destruction of vermin, especially rats; disinfection of excreta.) 

In cholera Asiatica and epidemic dysentery, one week after termina- 
tion of the disease. (Disinfection of excreta; avoidance of pollution 
of water, milk, etc.) 

In smallpox, six Aveeks. (Vaccination; disinfection of discharges.) 

In chickenpox, one week. (Disinfection of discharges and skin.) 



70 DISEASES OF CHILDREN 

In measles, two weeks. (Disinfection of discharges and skin.) 

In German measles, two weeks. (Disinfection of discharges and 
skin. ) 

In diphtheria, as long as diphtheria bacilli abound in the throat. 
(Disinfection of discharges.) 

In scarlet fever, while the desquamation lasts. (Disinfection of dis- 
charges and skin.) 

In whooping-cough, while whoop or vomiting lasts. (Disinfection 
of expectoration.) 

In mumps, two weeks. (Disinfection of sputum.) 

In erysipelas, two weeks. (Disinfection of the skin; antiseptic 
dressing.) 

In gonorrheal ophthalmia or urethritis, while gonococci are found in 
the discharges. 

Before leaving the isolation room, the patient should receive a 
cleansing, hot soap-water bath (including thorough scrubbing of the 
scalp, ears, finger- and toe-nails), and dressed anew with freshly dis- 
infected clothing. 

2. Disinfection of Excreta, or Fomites, etc. — In order to be on the 
safe side, the nurse should be instructed to disinfect the stools, urine, 
vomitus, sputum, and nasal, aural, conjunctival and vaginal discharges 
of the patient, regardless of whether or not they carry contagious matter. 

For Excreta. — Chloride of lime in powder or in solution. Four ounces 
of lime to one gallon of soft water. A sufficient quantity of this solu- 
tion should be thoroughly mixed with the feces, urine, sputum, etc., 
and allowed to stand for about three hours before emptying. 

Sputum is best collected in paper cups, or small cloths and immediately 
destroyed by fire. 

Bichloride of mercury in solution 1 :500 — a 7y 2 grain tablet in a pint 
of water. Copper sulphate in solution (5 per cent). Zinc sulphate in 
solution (10 per cent). Cresol or creolin in solution (5 per cent). 

For Clothing, Bedding, Linen, etc. — Destruction by fire — the safest 
measure. Exposure to dry heat at a temperature of about 300° F., or 
moist heat at 212° F., for two hours. Boiling for at least half an hour. 
Immersion in a bichloride solution (1 :2000) for about three hours. Fumi- 
gation by formaldehyde. (See below.) 

For the Hands, General Body, Dishes, etc. — Labarraque's solution 
(chlorinated soda, 10. per cent). Bichloride of mercury in solution 
(1:1000). Permanganate of potash in solution (1 ounce to a quart of 
water). Formaldehyde in solution (1:200). 

For Rooms, Furniture, Mattresses, etc. — Fumigation oij Formaldehyde 
Gas. — It may be employed in concentrated powdered form or in pastels. 
For small rooms the ordinary Shering lamp, which is constructed for 
vaporizing formaldehyde pastels will suffice. For large hospital wards, 



PREVENTION AND CONTROL OF DISEASE 71 

however, the " formaJdehycle-potassium-permanganate method" is best. 
It is of advantage to use a container consisting of a large open vessel 
protected from losing its heat by some nonconducting material such as 
asbestos. But one can get along almost equally as well by using a large 
milkpail set in a wooden bucket. 

The infected room should be made as air-tight as possible by snugly 
closing the windows and doors (keyholes, ventilators, fireplaces, etc.) 
by means of cotton or cloths. All articles intended for disinfection are 
freely exposed (mattresses, pillows, boxes and drawers should be opened). 

The fumigating apparatus is placed in the center of the room: 6% 
ounces of potassium permanganate (for each 1000 cubic feet of room 
space) are put in the container; and 16 ounces of a 40 per cent formalde- 
hyde solution (for each 1000 cubic feet of room space) are poured on 
top of the permanganate. The operator now quickly leaves the room, 
and closes the door or window. The room should remain tightly closed 
for about ten hours. 

After disinfection the disagreeable odor of the formaldehyde may be 
removed by sprinkling the room with ammonia water, and thorough 
ventilation. 

Fumigation with Sulphur. — The procedures are the same as with for- 
maldehyde. The sulphur, about 3 pounds for a room 10 feet square, 
is placed in an iron pan, supported by bricks and set in a tin vessel with 
water. The sulphur is ignited by live coals or a tablespoonful of alcohol 
lighted by a match. Sulphur fumigation should not wholly be depended 
upon after grave epidemic affections. 

Finally, it is well to bear in mind that sunlight is a disinfectant of 
great efficiency, and that prolonged exposure to its rays will materially 
aid in rendering rooms and fomites free from infectious matter. 

III. IMMUNIZATION— ACQUIRED IMMUNITY. BIOLOGIC DIAG- 
NOSIS AND THERAPEUTICS 

Medicine is rapidly reaching the goal of its highest ambition, the 
prevention and control of communicable diseases by "Nature's 
method," i.e., immunization. Stupid skepticism and boundless en- 
thusiasm are gradually yielding to deliberate experimentation and 
experience, and it does not require a very great stretch of imagination to 
predict that in the near future every communicable affection will be 
successfully resisted and combated by an antagonist evolved by the 
causal microorganism. 

In order to obviate unnecessary repetition we shall briefly describe 
the biologic products at present in use for diagnostic, protective and 
therapeutic purposes, and the results thus far achieved. 



72 DISEASES OF CHILDREN 

Variola Vaccine 

With the enforcement of vaccination by all civilized nations, smallpox, 
the most loathsome pestilence, has practically been eradicated from every 
well-regulated community. The principle of vaccination is the intro- 
duction into the human body of a weakened and harmless form of vac- 
cinia, cowpox, which renders the system immune (i. e., creates enough 
of antibodies to resist the disease) to variola. The vaccine is obtained 
from the vesicles that form on healthy young heifers as a result of inocu- 
lation with the virus of cowpox. 

Vaccination 

In the absence of contraindications (p. 74) every child of from six 
to twelve months old should be vaccinated, and revaccinated about 
seven years later. It is preferable to vaccinate at a time when neither 
excessive heat nor cold prevails, i. e., in May or October. The left arm 
at the insertion of the deltoid is usually chosen for the vaccination. In 
girls the leg may be preferred to avoid the possibility of an exposed 
disfiguring scar. The parts to be inoculated should be freely bared and 
cleansed with soap and water and thoroughly dried. When one inocula- 
tion is to be made, the epidermis should be abraded for about % i ncn i n 
diameter (until a serous exudate or a trace of blood occurs) by means 
of a sterile needle ; when several inoculations are to be made, they should 
be fully iy 2 inches apart. About a drop of vaccine is then gently 
rubbed into the denuded surface and allowed to dry. In successful 
vaccination the inoculated area begins to redden and swell on the third 
or fourth day ; on the fifth day a vesicle appears which gradually changes 
into an umbilicated pustule surrounded by a red areola. The pustule 
persists up to the eleventh or thirteenth day and then becomes covered 
by a scab. The latter remains stationary for about ten days longer, then 
falls off, leaving behind a red scar which gradually becomes white and 
glistening in appearance. The scar usually remains visible throughout 
life. Vaccination is associated with more or less marked constitutional 
symptoms. With appearance of the vesicle there is a slight rise of tem- 
perature ; the child is restless, sleeps badly, loses its appetite, and shows 
other signs of indisposition. Some children react more strongly than 
others, but if the vaccine is pure, the vaccinator clean and careful and 
the inoculated area kept free from irritation and infection, all the con- 
stitutional symptoms disappear by the twelfth day. Under adverse 
circumstances (e. g., old, impure lymph, defective asepsis, constitutional 
diseases) vaccination may be accompanied by very grave symptoms. 
The pustules may become very large, the redness in the vicinity very 
marked and extensive ; the axillary glands very much swollen and pain- 



PREVENTION AND CONTROL OF DISEASE 73 

ful; the whole arm very strongly infiltrated; the fever very high, up 
to 104° F. ; and convulsions and respiratory and gastrointestinal symp- 
toms may develop. Suppuration of the glands, phlegmonous processes, 
and even erj^sipelas may set in. Finally, vaccination may be accom- 
panied by transient or genuine nephritis, and cases of scrofula, tuber- 
culosis and syphilis are on record — undoubtedly preexistent, latent, but 
awakened by the acute inflammatory process. Occasionally the inocu- 
lation wound fails to cicatrize, continues to suppurate, or ulcerates. 
Children with a tendency to skin diseases may develop divers skin erup- 
tions, such as erythema, eczema, lichen, impetigo, psoriasis, a purpura- 
like eruption {purpura vaccinal oria) , general furunculosis, or, by trans- 
ference (autoinoculation) of the vaccine virus to some diseased parts of 
the skin, produce general vaccinia. The latter may also develop — usu- 
ally about the seventh or eight day — spontaneously, from within, inde- 
pendently of any external influences. The lesions, which may be dis- 
crete or confluent (grave), bear a certain resemblance to the regular 
vaccinal pox. In the same manner the vaccine may be carried to the 
eyes (vaccine ophthalmia) , and cause serious trouble. In fact, inocula- 
tion pustules have been observed on different portions of the body, and 
even on the tongue. Furthermore, vaccinia may also be transmitted 
to other persons by means of infected articles in use, fingers, bed sheets, 
bath water, sponges, etc. Hence the importance of a protective dress- 
ing over the vaccination mark (clean sterilized linen, sewed to the 
sleeve, changed every day) from the time the vaccine has dried up to 
the falling off of the scab, and of keeping the child's nails very short 
and its hands very clean. Bathing should be interrupted from the 
fifth to fifteenth day. Moist boric acid dressings are useful to re- 
duce the severe, local inflammatory process, and where the latter is 
grave, and the itching intense, a continuous, moist dressing with ni- 
trate of silver (% per cent) will prove especially beneficial. In de- 
layed healing the wound should be cauterized with a 5 per cent to 10 
per cent solution of nitrate of silver, and dressed like any other 
w r ound. Other complications arising should be treated according to 
indications. 

Revaccination. — As already suggested revaccination should be per- 
formed about seven years after the first vaccination, a period of time 
after which the immunity against smallpox usually ceases. In case of 
epidemics revaccination should be resorted to more frequently. Re- 
vaccination is also indicated to modify an attack of smallpox. In suc- 
cessful revaccination the local and systemic manifestations are essen- 
tially the same as after the first vaccination except that they are much 
milder in form. 



74 DISEASES OF CHILDREN 

Contraindications to Vaccination. — It is not advisable to vaccinate 
infants under three months, and children of all ages who are suffering 
from severe acute and recurrent skin affections, local or general syphilitic 
or tuberculous (scrofular) lesions, and great debility. 

Schick's Reaction" for Detection of Susceptibility to Diphtheria. — 
The outfit of the New York Health Department for the Schick re- 
action consists of a capillary tube (containing two minimum lethal 
doses for the guinea-pig of undiluted diphtheria toxin) and a small 
rubber bulb, and a bottle filled with 10 c.c. sterile physiologic salt 
solution (with 0.025 per cent carbolin acid). A. Zingher gives the 
following directions for its use: Break off one end of the capillary 
tube and push it carefully through the neck of the rubber bulb until 
it punctures the diaphragm within and enters the cavity of the bulb; 
then break off the other end of the tube. Hold the bulb between 
thumb and middle finger ; place the index finger on the opening of the 
outer end of the bulb and expel the toxin in the saline solution. Rinse 
out the capillary tube by repeatedly drawing up saline and expelling 
it into the bottle, then cork the bottle and shake the diluted toxin. 
Inject exactly 0.15 c.c. of the solution (representing 1/50 minimum 
lethal dose for the guinea pig) intracutaneonsly on the flexor surface 
of the forearm or arm. The injection is made with an all-glass syr- 
inge and fine needle. Instead of a syringe Koplik and Unger have de- 
vised a hypodermic shaped needle (with a handle) which is dipped into 
the undiluted toxin and introduced intradermically. In the absence 
of antitoxin in the child's blood, or in the presence of only a very minute 
amount, insufficient for protection against diphtheria, a circumscribed 
area of redness and infiltration, from y 2 to 2 cm. in diameter appears 
on the skin in from twenty-four to forty-eight hours, and persists for 
about a week leaving behind a brownish pigmentation. The positive re- 
action should not be mistaken for a pseudoreaction (which is due to 
proteins) that occasionally appears after the test. The pseudoreaction 
is earlier in its appearance as well as disappearance and is more infil- 
trated than the genuine reaction. About 40 to 50 per cent of the chil- 
dren react positively to the toxin testy All those who do so and are ex- 



*Discovered by Dr. Schick of Vienna in 1912. 

jSusccptibility of Various Ages to Diphtheria 

(as indicated by the Schick diphtheria-toxin skin test.) 

Age Susceptible 

Under 3 months , . 15 per cent 

3 to 6 months 30 per cent 

6 months to 1 year 60 per cent 

1 to 2 years 60 per cent 

2 to 3 years 60 per cent 

3 to 5 years 40 per cent 

5 to 10 years 30 per cent 

10 to 20 years 20 per cent 

Over 20 years 12 per cent 



PREVENTION AND CONTROL OF DISEASE 75 

posed to diphtheria infection, should immediately receive a prophylac- 
tic dose of diphtheria antitoxin. The test is also very valuable in scar- 
latina to determine the child's susceptibility to diphtheria, which forms 
so frequent a complication during the course of the disease. 

Antidiphtheritic Serum 

Diphtheria antitoxin is the purified blood-serum of a horse that has 
been rendered immune to diphtheria by a long course of treatment 
with diphtheria toxin. It is specific in its effects, having lowered the 
high (40 to 60 per cent) mortality from diphtheria to about 5 per cent 
— if administered early and in ample quantity. Furthermore, those 
exposed to diphtheria almost invariably escape infection by timely 
administration of the serum. It is practically harmless if free from 
admixture of virulent bacteria, and with introduction of the concen- 
trated, high-grade preparations and the application of greater care 
in handling and administration, the numerous disagreeable accompani- 
ments (fever, multifarious eruptions, articular swellings, etc.) have 
ceased to be as common and as severe as in former years. 

The dose of antitoxin for ordinary cases of diphtheria should be 
2,000 units for every year of the child's age up to five years, and 10,000 
units as the average dose for older children. If urgent, the injections 
may be repeated once or twice at intervals of from six to twelve hours. 
Malignant, especially laryngeal, cases require double doses. For pro- 
tective purposes a third of the ordinary dose usually suffices. The pro- 
tection usually lasts from four to six weeks. 

The antitoxin is administered by a sterile hypodermic syringe (or 
the mercantile serum-containing syringes) by deep injection into the 
anterior surface of the abdomen or thorax or outer surface of the 
thigh, which are rendered aseptic by soap, water, ether and alcohol, 
or tincture of iodine. The point of injection is subsequently sealed 
by sterile adhesive plaster. 

Diphtheria Toxin-Antitoxin Immunization 

During the last year the Department of Health of the city of New 
York has placed at the disposal of the profession the aforementioned 
product for the purpose of effecting permanent immunity in persons 
susceptible to diphtheria as demonstrable by Schick's reaction. 

"The usual injection for all ages is approximately 400 times the 
fatal closef for a half -grown guinea pig, to which has been added just 



fA. Zingher (Jour. Am. Med. Assn., Nov. 13, 1920) found that quite a number of Schick 
test-outfits furnished by commercial laboratories do not contain a sufficient amount of toxin. 



76 DISEASES OF CHILDREN 

sufficient antitoxin to neutralize it. This is about four units of anti- 
toxin. The injection usually contains 1 c.c. of fluid and is made sub- 
cutaneously. The mixture is tested very carefully for its harmlessness 
before being used, and if so tested is absolutely safe. As it ages, the 
toxin disappears more rapidly than the antitoxin. A second and third 
injection of the same amount made at weekly intervals add greatly 
to the quantity of the antitoxin development from the first injection. 

The Local and Constitutional Reaction 

"The diphtheria toxin-antitoxin mixture contains besides the neutral- 
ized toxin a considerable amount of protein substance. This is partly 
formed of the proteins originally present in the broth in which the 
bacilli were grown and partly from the remains of broken down or di- 
gested bacilli in the cultures. The reaction to the protein in the injec- 
tion is similar to the reaction to the typhoid vaccine but it is of less 
severity. 

' ' The element of age is very important. The infant shows in the great 
majority of cases neither a local nor a constitutional reaction, while 
grown up children and adults exhibit in perhaps 30 per cent of the cases 
considerable local swelling and more or less definite constitutional 
disturbance. Within 24 to 72 hours all disturbance is over. No lasting 
deleterious results have occcurred. Children of ages between one and 
ten years vary in the amount of reaction according to their age. The 
youngest shows the least and the oldest the most. 

The Immunization Response in Susceptible Children 

"Those persons who are naturally immune against diphtheria are 
usually so from having antitoxin, but may be so from the possession of 
other protective substances. The antitoxin we can measure by the Schick 
test, but we have no practical way to detect bactericidal substances. 

The Immunizing Results 

"These are measured by the percentage of susceptible persons who be- 
come immune, and by the persistence of the immunity. The antitoxin de- 
velops slowly after the injections are begun and gradually increases. In 
only a few cases does an appreciable amount of antitoxin develop in less 
than three weeks after the first injection. The majority respond during 
the second month. There are a few who become fully immune only dur- 
ing the sixth month. The results in 529 children who were carefully ob- 
served were as follows: 



PREVENTION AND CONTROL OF DISEASE 77 

Number of Doses No. of Children Im- -p tT 

of 1 c.c. Toxin- No. of Children mime Three Months f. G1 Z, " T 1 

Antitoxin after Injection after Three Months 



1 


239 


175 


73 


2 


89 


80 


90 


3 


201 


191 


95 



" These figures approximately agree with our results in thousands of 
cases. In young infants who are still retaining their parents' antitoxin, 
transferred to them passively before birth, we have less successful results. 
Tested one year afterwards only about fifty per cent were found to be 
immune. This percentage is about twice as great as among those not 
treated. Some 2,400 infants of an age under one week have been injected 
with absolutely no bad effect." Similar observations were made by J. 
Blum in an Infant Asylum accommodating 1,076 children.* 

"The inmates of two institutions in New Jersey have been Schick 
tested for the fifth time for immunity to diphtheria, after one active im- 
munization with toxin-antitoxin. The children were found to have re- 
mained immune from four to four and a half years. This is the longest 
period over which such tests have been made, so far as is known. The 
Leake and Watts Home, in New York, was also tested and the few chil- 
dren remaining in the home, since the first test four years ago, were 
found to be still immune. 

"The 4,500 inmates of the State Insane Asylum at Kings Park have 
been Schick tested for immunity to diphtheria, and all patients showing 
susceptibility immunized by toxin-antitoxin. 

"The children at the Colored Orphan Asylum at Riverdale-on-the- 
Hudson, who had previously received toxin-antitoxin, have been retested 
by the Schick test. The result shows that 104, out of the 111 children 
injected, have developed active immunity to diphtheria." 

Antitetanic Serum 

Like diphtheria antitoxin, antitetanic serum is obtained from the 
blood of horses previously immunized to the toxin of the tetanus 
bacillus. Its efficacy as a curative remedy is as yet awaiting indis- 
putable demonstration, but its value as a preventive of tetanus is 
authoritatively established. Whenever there is reason to fear tetanus 
infection {e.g., contused or lacerated wounds — toy-pistol wounds — 
soiled with earth or other foreign matter) especially when an unusu- 
ally large number of tetanus cases prevail, it is imperative promptly to 
administer tetanus antitoxin as a prophylactic measure. 



* Active Immunization Against Diphtheria in a I^arge Child-Caring Institution, Am. Jour. Dis. 
Child. July, 1920. 



78 DISEASES OF CHILDREN 

Tetanus antitoxin is usually administered intraspinally, intravenously, 
and subcutaneously in doses of 1,000 to 1,500 units; the dose is repeated 
as a preventive measure after ten days, as a curative (3,000 to 5,000 
units) once a day. (See p. 227.) 

Antimeningitis Serum (Flexner) 

This serum acts specifically in cerebrospinal meningitis due to the 
diplococcus intracellularis (Weichselbaum) only. If used by the sub- 
dural and intravenous methods in suitable doses, promptly and at 
proper intervals, it is capable of greatly diminishing the fatality gen- 
erally due to the disease ; of reducing the period of illness, and, in a 
large measure, of preventing the chronic lesions and types of the 
affection. 

After reducing the intracerebrospinal pressure by withdrawal, by 
lumbar puncture (Fig. 175), of about 30 to 60 c.c. of cerebrospinal fluid, 
we inject 30 c.c. of the serum into the spinal canal by means of an 
antitoxin syringe or by gravity through a funnel and rubber tube 
attached to the puncture needle. The modern serum containers 
greatly facilitate the administration of the serum. The injection is 
repeated daily for three or four days or longer until the diplococci 
disappear. In fulminating cases a second dose may be given after the 
lapse of twelve hours. If after a period of apparent recovery the 
symptoms recur and the diplococci reappear, the injection should 
be repeated. The serum is practically useless in cerebrospinal menin- 
gitis after the condition of hydrocephalus has supervened. 

"Up to a short time before the war began a single type of meningococ- 
cus was generally accepted as the cause of epidemic meningitis. Dopter 1 
was the first to classify meningococcus-like organisms into distinct types. 
In connection with a recent very lucid description of the manner in 
which the types of meningococcus came to be recognized, he 1 has de- 
scribed in detail the modifications which have resulted in the treatment 
of meningitis. Four types of meningococci are now generally recognized, 
designated as Types A, B, C and D. Type A appears to have been the 
common one before the war, being found according to Dopter in from 95 
to 96 per cent of the cases. Of the other types, sometimes called para- 
meningococci, B is most common, C and D exceptional. Infections by 
Type B increased during the first two years of the war, and at the end 
of 1917 about 50 per cent of the cases in the French army were of this 
form. Each of these various types of organism is affected only by its 
own specific serum. A case of meningitis caused by the Type B Meningo- 



iDopter, C: Recent Work on Cerebrospinal Fever, Lancet, French Supplement, 1:1075. 
(June 21) 1919. 



PREVENTION AND CONTROL OF DISEASE 79 

coccus is not influenced by a serum prepared from Type A organisms. 
Consequently it has been necessary to prepare serums from each type 
of organism for use in the treatment of meningitis due to the correspond- 
ing type. 

"For the most efficient serum treatment of epidemic meningitis, two 
things now appear essential: (1) an accurate biologic determination of 
the type of organism concerned in the individual case, and (2) the 
administration of the serum prepared from the corresponding type. 
Doptor is not in favor of using polyvalent serum except as a measure 
of precaution until the laboratory examination has determined the type 
present in the case. As soon as the type is known, the corresponding 
monovalent serum should be substituted. He believes that 'too much 
poly valency might conceivably involve risk of diminished potency. ' Those 
who have treated meningitis with serum have observed that occasionally 
cases occur which are not appreciably benefited by the polyvalent serum 
used, and in such cases the spinal fluid does not clear up neither do the 
meningococci decrease in the fluid, as is usual in most cases. Sometimes 
another make of polyvalent serum may be active, and it is advised to 
make use of this expedient, with the hope that a strain of meningococcus 
corresponding to the one causing the infection rtiay have been among 
those employed in preparing the serum. At best this is not satisfactory. 
It is much to be desired that serums should be prepared from the several 
types so that they may be available for cases which do not respond 
promptly to the polyvalent serums. Accurate differentiation of the 
type of infecting organism by biologic tests is essential before the treat- 
ment can be carried out with a high degree of precision. It has been 
found that the cases prevailing in a group of individuals both in the 
meningeal exudate and in the nasopharynx of carriers are usually of one 
type. Mathers and Herrold found that, in a camp near Chicago, almost 
86 per cent of the cases of meningitis were due to Type A (Group 1), 
and in the city of Chicago at the same time more than 86 per cent of 
the cases were due to Type B (Group 2). If investigation revealed the 
prevalence of one type in a community or epidemic, a serum high in im- 
mune bodies for that type would be reasonably used for routine treatment 
if it were not feasible to make a biologic differentiation in each case. As 
the abnormal conditions of army camps disappear, it will be of interest to 
note whether the prevailing type of meningococcus will again be the Type 
A, as was apparently the case before the war. Study of cases of epidemic 
meningitis has served also to emphasize the fact that the meningococci 
are found not only in the meninges, but also often in the blood, joints, 
etc. When serum is injected intraspinally, it rapidly passes into the 
circulation ; but it is desirable to secure a greater concentration of anti- 



80 DISEASES OF CHILDREN 

bodies in the blood than is secured in this way. This can be brought 
about by intravenous or intramuscular injection of serum. It would 
probably be a useful practice to combine intramuscular with intraspinal 
injection in all cases. When intravenous injections are used, all pre- 
cautions to avoid anaphylactic shock should be taken." (Jour. Am. 
Med. Assn., Oct. 11, 1919.) 

With the demonstration of the meningococcus in the blood, sev- 
eral clinicians have recently begun to administer antimeningococcus 
serum intravenously as well as intraspinally. The intravenous method 
is recommended especially in severe cases. Major W. W. Herrick, who 
has had under observation 265 cases of epidemic cerebrospinal menin- 
gitis, at Camp Jackson, and has employed this method with a great 
reduction in the ordinary mortality in this affection, offers the fol- 
lowing suggestions which relate, of course, to adults, but can readily be 
modified to suit the needs of children : 

Important Points in Intravenous Serum Treatment. — It must be 
employed with boldness, yet with care. One must be prepared 
to give from four to eight massive injections by vein of from 
80 to 150 c.c. during the acute stages of the disease or a period 
of from two to four days. There is much more danger in insufficient 
than in excessive intravenous serum administration. He has, in fact, 
in 128 cases so treated, had no serious serum effects. His regrets have 
been that serum was not more freely used in many of the early cases. 

The desensitization by subcutaneous injection of 1 c.c. of serum one 
hour before the introduction of serum into the vein and the^cautious 
injection of the first 15 c.c. at the rate of 1 c.c. per minute are the 
secrets of safe intravenous serum therapy. Immediate stopping 
of the injection with the appearance of dyspnea, pallor, cyanosis, 
vomiting, weak, rapid or irregular pulse or other immediate serum 
effects is essential. Kenewal of the attempt after two or three hours 
is rarely unsuccessful. Even those patients thoroughly sensitized to 
serum by earlier courses of treatment can be treated safely with these 
precautions. 

In those prolonged cases in which meningococci persist in the spinal 
fluid and in which the patients are made uncomfortable by intraspinal 
injections, showing increased opisthotonos, and severe pain in the 
head or back or lower extremities following the treatment, it is better 
to omit all interference. At times drainage may be necessary wuth 
or without further intravenous injections. Many of these prolonged 
cases apparently become intolerant of intraspinal serum injections. 
If satisfactory response does not follow a series of eight or ten intra- 
spinal treatments, it is generally best to cease injecting serum intra- 



PREVENTION AND CONTROL OF DISEASE 81 

spinally, continuing drainage only if there is discomfort from increased 
intracranial pressure or apparent danger of blocking the foramina. 

In relapsing cases the entire cycle of treatment must be repeated 
with the same thoroughness and care used in the initial course. The 
organism cultivated from the blood or spinal fluid may be used to 
determine the presence of agglutinins in the serum employed. Valua- 
ble evidence can thus be obtained as to the specificity of the serum for the 
strain of meningococcus present. This is of the highest importance. 
Therapeutic results seem to parallel the agglutinin content of the serum 
for the special strain of meningococcus involved. Commercial serums 
are frequently lacking in high agglutinin content, and their therapeu- 
tic effect is often disappointing. In the absence of desirable results 
from a given serum, use should promptly be made of serum from an- 
other source. This may be of vital moment to the patient. The stand- 
ardizations of serums by governmental authority is an urgent need. 

Of course, the dosage varies with the age of the patient. A third 
of the adult dose ought ordinarily to suffice for children under five years 
of age, and one-half of the adult dose for older children. In young 
infants the longitudinal sinus route may be used for the injection of 
the serum; in older children the basilic vein. 

Several other sera (e.g., antipneumococci, antidysenteric) are now on 
the market. Their curative merits, however, are still unestablished. 

Bacterial Vaccines 

Following upon the great researches of our contemporary pathol- 
ogists, bacteriologists and clinicians, A. E. Wright, of London, has dem- 
onstrated the remarkable fact that emulsions of dead bacteria — bac- 
terial vaccines so called — if injected subcutaneously increase chemo- 
taxis and, therefore, phagocytosis. The molecular group produced 
by the presence of the killed bacteria in the blood that renders the 
living bacteria of the same species a ready prey to the phagocytes 
he designated "opsonin," corresponding to the Greek verb "opsono" 
— I cater for, I prepare victuals for. He also devised a method to 
determine the "opsonic index," of sensitizing power of the blood, 
so that in a given case of infection one can, as it were, measure the 
opsonin content of the blood and increase it, if found below par. 

Bacterial vaccine therapy is mostly limited to local infections, e. g., 
furunculosis, phlegmons, carbuncles, where the offending microor- 
ganisms can readily be determined by microscopic examination of the 
discharges, and accordingly the vaccine chosen to meet the indications. 

Of the numerous vaccines thus far recommended, the staphylococcus 



82 DISEASES OF CHILDREN 

and streptococcus vaccines have actually stood the test and proved 
of great utility. They are deserving of more general application. 

Favorable results are also on record from the use of vaccines pre- 
pared from the bacillus coli (in colicystitis) ; from gonococci (in gonor- 
rheal affections, especially vulvovaginitis); from typhoid bacilli (in 
typhoid, especially as a preventive measure) and from combined pertussis 
vaccine (as a preventive, and in the early stages of whooping-cough as 
a therapeutic measure. See "Pertussis"). 

The inoculations are given by means of a sterile hypodermic syr- 
inge, in the same manner as antitoxin. In children particularly it is 
advisable to begin with small doses, let us say, 50 million staphylococci, 
or 2 million streptococci, and to increase the dose of each succeeding 
injection. 

In order to obtain prompt results it is essential to know not only 
the specific infecting microorganism but also its variety; for instance, 
whether the offending staphylococcus is an aureus, albus, or citreus, 
since the employment of a different variety of vaccine is apt to prove 
useless. For Influenza Vaccines see p. 354. 

Bacterial vaccines are often prepared directly from cultures obtained 
from the individual to be treated — autogenous vaccine. 

Tuberculin Tests and Tuberculins 

These bacterial products are invaluable in the early diagnosis of 
tuberculosis in children. By means of tuberculin we are enabled to 
detect from 90 to 95 per cent of cases of tuberculosis, often at a time 
when no other clinical manifestations or bacteriologic examinations 
indicate its presence. It has furthermore the great advantage that 
its use calls for no complicated procedures, methods, calculations or in- 
struments. According to von Pirquet, the specific test is based upon 
the fact that an individual contracting tuberculosis develops a hyper- 
sensitiveness of the tissues (so-called "allergia") to the poison of tu- 
bercle bacilli which is manifested by a local inflammation or systemic 
disturbance. 

The tuberculin reaction may be elicited in the following manner : — 
1. The Cutaneous Method (von Pirquet). — After cleansing the ante- 
rior surface of the forearm with soap, water and ether, two small abra- 
sions (as for vaccination) or punctures of the skin are made at an inter- 
space of about 2 inches. On one of the two abraded spots a drop of a 
50 to 100 per cent solution of old TB is applied and allowed to dry. 
If tuberculosis is present, a red pea- to bean-sized papule appears after 
from twenty-four to forty-eight hours at the point of contact of the 



PREVENTION AND CONTROL OF DISEASE 83 

injured skin and tuberculin, while the other nontuberculized spot re- 
mains free from the inflammatory reaction. 

2. Conjunctival Method (Calmette). — A drop of !/ 2 to 1 per cent (try- 
ing the weaker solution first) of old TB solution is instilled into the con- 
junctival sac of one eye. In the presence of tuberculosis a positive re- 
action is manifested within twenty-four hours by reddening of the 
caruncles and semilunar fold of the conjunctiva and injection of the 
corneal conjunctiva. The other eye remains normal. 

3. Nasal Method (Wolff-Eisner and Calmette). — A cotton tampon sat- 
urated with a 1 per cent TB solution is applied against the nasal septum 
and allowed to remain there for about ten minutes. In from eighteen to 
forty-eight hours a peculiar exudation appears which dries and forms 
a yellow crust upon a congested mucosa. From this clumps of extrav- 
asated red cells project here and there as minute reddish points. The 
crust generally falls off in from four to six days. 

4. Percutaneous Method (Moro). — This method is less reliable than 
the aforementioned procedures. A 50 per cent tuberculin ointment is 
rubbed over about a square inch of epidermis until absorbed. If the 
reaction is positive, papules appear within from twenty-four to forty- 
eight hours. 

5. Subcutaneous Method. — Very rarely employed in young children. 
Tuberculin Therapy. — Tuberculin treatment, like so many similar 

new, in their therapeutic effects grossly inflated, remedial measures, 
has for several years been relegated into oblivion. Yet tuberculin, 
properly employed and in suitable cases is of remarkable benefit in tu- 
berculous affections, more particularly in those of the small bones, 
joints, glands and skin. Its curative action is due to stimulation of de- 
fensive powers of the body and its resistance to the pathogenic action 
of the tubercle bacillus and its toxin. If these means of defense are 
not in a condition to be favorably influenced by the tuberculin, the 
therapeutic results, of course, will be nil. Hence the importance of be- 
ginning the treatment as soon as tuberculosis is diagnosed or even sus- 
pected (E. Beraneck). Furthermore, the important thing is to begin 
with a small dose of a very dilute solution, and to continue to inject 
(twice a week) three or four times at least before arriving at any 
definite estimate of the need of a larger dose. If the effect seems 
favorable, the same dosage should be continued for weeks or months, 
so long as the patient is deriving benefit from the treatment. On the 
other hand, if three or four injections of the initial small dose seem to ex- 
ert no beneficial effect, a somewhat larger dose is administered and 
its therapeutic action carefully observed in the same manner as with 
the smaller dose. The initial dose of the tuberculin solutions, presently 



84 



DISEASES OF CHILDREN 



to be enumerated, should be one-millionth of a milligram in non- 
febrile cases and a smaller dose in those showing moderate fever. 
The subcutaneous injection is made with the usual aseptic precautions. 
If the injection is followed by marked systemic disturbance and 
high fever, the treatment is temporarily discontinued and a smaller 
dose begun with, after the fever has subsided. 

The tuberculin (Koch) is diluted with sterile physiologic salt solu- 
tion or y 2 per cent carbolic acid water in the following manner: 



Sol. No. 


1 


Tuberculin 


1 


e.c. 


1 c.c. 


0.1 






Diluent 




9 


c.c. 






Sol. No. 


2 


Sol. No. 


1 


1 


c.c. 


1 c.c. 


0.01 






Diluent 




9 


c.c. 






Sol. No. 


3 


Sol. No. 
Diluent 


2 


1 

9 


e.c. 
c.c. 


1 c.c. 


0.001 


Sol. No. 


4 


Sol. No. 
Diluent 


3 


1 
9 


c.c. 
c.c. 


1 c.c. 


0.0001 


Sol. No. 


5 


Sol. No. 
Diluent 


4 


1 
9 


e.c. 
c.c. 


1 c.c. 


0.00001 


Sol. No. 


6 


Sol. No. 
Diluent 


5 


1 
9 


c.c. 
c.c. 


1 c.c. 


0.000001 


Sol. No. 


7 


Sol. No. 
Diluent 


6 


1 
9 


c.c. 
c.c. 


1 c.c. 


0.0000001 


Sol. No. 


8 


Sol. No. 
Diluent 


7 


1 
9 


c.c. 
c.c. 


1 c.c. 


0.00000001 


Sol. No. 


9 


Sol. No. 


8 


1 


c.c. 


1 c.c. 


0.000000001 



Complement-Fixation Reaction in Tuberculosis 

During the last ten years considerable progress has been made in 
the detection of tuberculosis by the aforementioned reaction. The 
technic is the same as in the Wassermann reaction (q. v.) except for 
the antigen, which consists of an emulsion of ground tubercular bacil- 
lary bodies. The longer the bacilli are ground, the better the antigen. 
It matters but little whether the bacilli are triturated dry (Miller), 
wet (Fleischer), by boiling in glycerin (Petroff) by dissolving off the 
wax and suspending (Cooke, Wilson), or allowing it to occur by lysis 
(Corper). From a careful experience with 6500 tests, W. W. Watkins 
and C. N. Boynton* have recently formulated the following conclu- 
sions : 

The Miller antigen is serviceable, practical and efficient for the com- 
plement-fixation test in tuberculosis. 

The reaction is specific for tuberculosis and, when positive, should 
be interpreted as indicating tuberculosis of some degree of activity. 
When the Wassermann and tuberculosis fixation reactions are both 
positive, they should be interpreted without relation to each other. 

The positive fixation reaction can be interpreted as indicating tuber- 



*Jour. Am. Med. Assn., Oct. 



1920. 



PREVENTION AND CONTROL OF DISEASE 85 

culosis, either active at the time, or recently active. The focus may 
or may not be of clinical significance, which fact must be determined 
by other means. 

The negative fixation reaction indicates either absence of infection, 
excessive activity of the disease, exhausting the antibody, or arrest 
of the disease with spontaneous disappearance of antibody no longer 
required. 

Serum Diagnosis of Syphilis (Wassermann) 

The substances employed in this reaction are as follows: (1) Com- 
plement. One to ten dilution of fresh guinea pig serum in normal 
(0.85 per cent) salt solution. (2) Antigen. Alcoholic extract of a 
syphilitic organ or suspension of an organ in weak carbolic acid solu- 
tion (1 per cent). (3) Amboceptor. Inactivated serum of rabbit 
which has been highly immunized against sheep red-cell by five or six 
injections of increasing amounts of sheep red-cells. The amboceptor 
is standardized by putting in each of a series of test tubes 1 c.c. of 
complement and 1 c.c. of 5 per cent emulsion of sheep red-cells. Differ- 
ent amounts of the inactivated rabbit serum are added to the tubes, be- 
ginning with 0.01 c.c. to 0.1 c.c. The tubes are then incubated one hour. 
That in which complete hemolysis occurs contains just enough of ambo- 
ceptor to dissolve 1 c.c. of 5 per cent emulsion of sheep red-cells. Double 
the quantity is the amboceptor to be used. Suspected serum to be used is 
drawn from a superficial vein with a medium-sized exploratory needle 
under strict aseptic precautions, about 5 c.c. being sufficient. The blood 
is centrifuged and the cleared serum inactivated by heat for thirty 
minutes at 56° 0. 

Test. — Put 1 c.c. of complement, 2 drops of suspected serum, about 
0.1 c.c. of antigen in test tube and incubate one hour at 37° C. Then add 
the amount of amboceptor, determined by standardization, and 1 c.c. 
of 5 per cent emulsion of sheep 's red-cells suspended in normal salt solu- 
tion and incubate again for one hour. Then place in ice box for six 
hours. Complete hemolysis is indicated by a clear burgundy-red solu- 
tion, showing no precipitate. No hemolysis is indicated by a solid, 
opaque sediment of the unaffected sheep cells at the bottom of the tube, 
while the supernatant fluid is clear and colorless. 

Result: Hemolysis, no syphilis; syphilis, no hemolysis. The control 
test is the same except that the antigen is omitted. (After G. M. Gould 
and R. J. E. Scott.) 

The Noguchi method of the serum diagnosis of syphilis is a modifica- 
tion of the Wassermann reaction. "(1) He prepares the antigen by 
extracting a lipoid substance from the liver and heart of dogs and cows. 



86 DISEASES OF CHILDREN 

(2) Instead of using sheep's corpuscles in the hemolytic series, he em- 
ploys human corpuscles, owing to the fact that a certain percentage of 
human sera tested produced hemolysis of the sheep's corpuscles. (3) 
In his test, therefore, he obtains the hemolytic amboceptor by immuniz- 
ing rabbits with washed normal human corpuslces. (4) Another im- 
portant improvement in the technic is the preservation of the specific 
antigen and the hemolytic amboceptor, which rapidly lose their strength 
in solution, in a dried form by soaking measured strips of filter-paper 
(.5 mm. square) with each. His test is carried out as follows: A strip 
of antigen filter-paper is brought in contact with a definite quantity of 
the human serum to be tested and fresh guinea-pig's serum added, the 
whole being suspended in isotonic salt solution. This is allowed to stand 
at incubator temperature and then the hemolytic series added by taking 
a strip of the hemolytic amboceptor paper and a definite quantity of 
washed normal human blood corpuscles." — (Tyson's Practice of Medi- 
cine.) 

Serum Diagnosis of Typhoid 

(Gruber-Widal) 

The blood of persons suffering from typhoid, when added to a broth 
culture of typhoid bacilli, arrests the characteristic movements of 
these germs and produces their agglutination and sedimentation. 




1^ 
Fig. 5. — Stages in Widal reaction of typhoid (after Eobin). 

This phenomenon may be observed macroscopically in a suspension 
of bacteria in test tubes ; or microscopically when the bacteria are mixed 
with the blood and mounted in a hanging drop preparation. The test 
is generally positive in typhoid patients after the fifth day of the disease 
and several weeks thereafter. 

The blood (or serum from a blister) is obtained from the skin cov- 
ering the ear lobe. After cleaning this part, the lobe is pricked with 



PREVENTION AND CONTROL OF DISEASE 87 

a sterile needle, and two drops of blood are placed on a glass slide, one 
near eaeli end, and allowed to dry in the air. The examination can 
then be undertaken any time thereafter by diluting one drop of the 
blood in ten or twenty parts of the typhoid culture. 

Weil-Felix Reaction of Typhus Fever 

What is known as the Weil-Felix reaction has recently come into 
use abroad in the diagnosis of typhus fever, and as its value has seem- 
ingly been proved, it should be employed for confirmation of clinical 
diagnosis in all suspected cases of typhus or continued fever. 

This reaction is similar to the Widal test in typhoid, and consists in 
testing the agglutinating power of the patient's blood serum on a 
suspension of bacilli obtained from cases of typhus fever, which have 
tentatively been classed as various members of the Proteus group of 
organisms. The bacilli in question were described by Weil and Felix 
as short Gram-negative rods, slightly motile, forming blue colonies on 
Conradi-Drigalski medium, and colonies which become pink on Endo 
medium. The organisms, according to these authorities, ferment dex- 
trose and curdle milk, with the development of an acid reaction, and 
liquefy gelatin. They are also stated to produce indol. 

The technic of the agglutination test (as recommended by Weil 
and Felix) is as follows: The growth of the proteus-like bacillus on 
an agar-slant is suspended in a small quantity (2 c.c.) of 0.9 per cent 
salt solution, and this is mixed in the proportions of 1 to 25, and 1 to 
50, with serum from the suspected case. Hanging drops of these 
dilutions are then examined microscopically after a half hour's incu- 
bation at 37° C. 

In positive cases, agglutination should take place in dilutions of 1 
to 25, on the 6th day; and, by the 12th day of the disease, in dilutions 
of as great as 1 to 200, or higher. 

Allergy- or Food Idiosyncrasy-Test 

This test is of great diagnostic and hence therapeutic value in de- 
termining food idiosyncrasies which are not rarely responsible for 
marked gastrointestinal disturbances, skin affections and asthma. 

The technic is the same as in von Pirquet tuberculin test, using the 
soluble food product instead of the tuberculin. 

A positive reaction is manifested in from ten to thirty minutes by 
the appearance of a blotchy papular eruption about i/ 2 i nen in diameter, 
accompanied by local or general itching of the body. This may be 
followed by asthmatic breathing. A positive reaction, of course. 



88 DISEASES OF CHILDREN 

calls for the removal of that particular kind of food from the dietary, 
until the susceptibility has disappeared. 

The following food-testing-products are marketed by the Arlington 

Chemical Company, Yonkers, N. Y., or Squibb and Sons, New York. 

Almond Lactalbumin 

Banana Lamb 

Barley Lentil 

Bean Lettuce 

Beef Lobster 

Buckwheat Oats 

Cabbage Onion 

Carrot Orange 

Casein Oyster 

Clam Pea 

Cocoa P'eanut 

Codfish Pork 

Corn Potato 

Crab Eice 

Cucumber Eye 

Egg Albumin Squash 

English Walnut Strawberry 

Grapefruit Tomato 

Haddock Wheat 



IV. MATERIA MEDICA AND THERAPEUTICS 

(Including Hydrotherapy, Electricity, Massage, and Climatotherapy) 

No one method of treatment suits all cases. Some diseases sub- 
side spontaneously, if let alone; others go from bad to worse if not 
treated promptly and energetically. Some affections yield Readily 
to biologic remedies, others to crude drugs or synthetic pharmaceuti- 
cal preparations, and again others respond to change of climate, mode 
of living and eating, and to remedial measures other than pharma- 
ceutical, such as hydrotherapy, massage, electricity and the like. 

Our duty being to alleviate suffering, we owe it to our patients to 
keep pace with the advances of the time and to employ every useful 
method of treatment regardless of its source or character. "The pe- 
riod of exclusiveness is past." While a certain degree of conserva- 
tism is always wise and safe, skepticism to well-tried remedies is 
worse than folly. 

Hydrotherapy 

The virtue of water as a therapeutic agent varies with the idiosyn- 
crasy of the patient, the temperature of the water employed and the 
method of its application. 

Heat applied to the surface of the body produces a relaxation of the 
vasomotor system. The cutaneous vessels dilate and become more ac- 



PREVENTION AND CONTROL OF DISEASE 89 

tive, diaphoresis ensues, and effete matter is eliminated. The volume 
of blood in the deeper structures is diminished; hence, congestion re- 
lieved. The temperature of the body is first increased, but after free 
diaphoresis considerably lowered. 

Cold contracts the terminal blood vessels and stimulates the internal 
circulation. It reduces the temperature of the body not only by con- 
duction but also by inhibition of heat production. Soon after discon- 
tinuance of the cold a reaction takes place, respiration becomes deep 
and full, more carbon dioxide is excreted and the supply of oxygen 
is increased. The pulse, which is at first feeble, soon becomes full and 
strong; the chilliness and rigor disappear, and a sensation of warmth 
pervades the body surface. The blood current in the capillaries becomes 
gradually accelerated and the internal circulation relieved of its tension. 

The External Use of Water. — Neither extreme heat nor extreme cold 
should be employed in the treatment of diseases of children. Heat 
should be avoided on account of the severe depression, and cold because 
of the shock it is apt to produce. 

Cold Sponging. — In the employment of cold water in the treatment 
of diseases of children, sponging advantageously supplants the cold 
bath. The temperature of the water should vary between 70° and 90° 
F. Three basins of water, one each of 70° F., 80° F. and 90° F., respec- 
tively, are placed at the bedside. The child is stripped and laid upon 
a blanket, and by means of cloths the surface of the body is sponged 
for from two to three minutes, in the following order of succession: 
face, neck, chest, back, abdomen, buttocks, upper and lower extremities. 
The warmest water (90° F.) is used first and the coldest (70° F.) last. 
Each part of the body should be thoroughly dried immediately after it 
has been sponged. The indications for the use of the sponge bath are 
hyperpyrexia and nervous irritability; constitutional disorders, such as 
anemia, chlorosis, scrofula, etc., and in cases in which a general tonic 
effect is desired. In the latter conditions sponging should be followed 
by active friction. 

Cold Wet Pack. — The child is stripped and blankets are placed over and 
under it. A small sheet is dipped in water at a temperature of 70° to 90° 
F., thoroughly wrung out and wrapped loosely around the patient. The 
child's body is then enveloped in the blankets. To reduce high tem- 
peratures, for example, in typhoid or pneumonia, ice may be rubbed 
over the pack. The next pack is applied after an interval of ten min- 
utes and may be repeated from ten to twelve times in twenty-four hours. 
The feet should be kept warm by artificial heat. 

Vapor Pack. — If the cold wet pack is allowed to remain in position for 
from one to two hours and loss of body heat prevented by thoroughly 



90 DISEASES OF CHILDREN 

covering the child with woolen blankets, the cold pack is converted into 
a warm pack which produces effects similar to those obtained from a 
vapor bath — namely, free diaphoresis, lowered activity of the nervous 
system, calm and repose, and equalization of the internal circulation. 
The vapor pack is, therefore, invaluable in acute catarrhal conditions 
of the air passages, in nephritis, dropsical effusions, muscular rheuma- 
tism, -eclampsia, hyperesthesias, etc. 

Wet Local Compresses (Priessnitz). — Cold Compresses. — These are ap- 
plied in all forms of local inflammation, to relieve pain, swelling, heat 
and redness. In order to obtain good results, the temperature of the 
water should vary between 50° and 60° F., and the compress left in 
place and kept cold either by frequently sprinkling cold water over it 
or by the application of an ice bag. 

Indications: Headache, angina, acute pharyngitis and laryngitis, 
hemoptysis, appendicitis, intestinal hemorrhage, etc. 

Warm Compresses. — "While cold compresses delay the flow of blood 
and cell activity, warm compresses accelerate the blood-current and 
promote cell activity. They are applied by means of cloths immersed 
in water at a temperature of about 100° F., thoroughly wrung out, 
then covered with flannel and rubber tissue or oiled silk to prevent rapid 
evaporation and cooling. The compresses should be changed as soon as 
they become dry. 

Indications: Neuralgia of the head; throat affections after subsidence 
of the acute inflammatory stage, to promote absorption of diseased prod- 
ucts; in exudative pleuritis; in bronchitis, to allay severe cough and to 
promote expectoration; in all spasmodic conditions of the intestines; to 
hasten suppuration and relieve stasis. 

Baths. — Tepid Bath. — This is a very useful bath in children. The 
temperature of the tepid bath varies between 85° F. and 92° F. It is 
employed in diseased conditions requiring soothing, for example, in erup- 
tive skin diseases and as an antipyretic in infectious diseases. 

Warm Bath. — In a general sense, this is the most valuable bath in the 
treatment of diseases of children. It tranquilizes the nervous system, 
equalizes the circulation, produces diaphoresis and reduces temperature. 

Indications: All spasmodic conditions; affections of the lungs and 
kidneys; exanthematous diseases, and nervous affections, such as hys- 
teria, etc. The temperature of the bath should vary between 92° F. 
and 98° F. The patient should remain in the bath for from two to 
five minutes. The warm bath is sometimes emplo} r ed as a permanent 
bath, in extensive burns and wounds, and in skin diseases associated 
with intense itching. The patient is suspended in the bath on a sheet. 



PREVENTION AND CONTROL OF DISEASE 91 

The water is kept at an equal temperature by proper arrangement of 
inflow and outflow. 

Hot Bath. — The temperature of the hot bath may be carried gradually 
as high as 108° F., and the patient should remain in the bath for 
from one to three minutes. It is very useful in collapse, convulsions 
and chronic rheumatic conditions. It is occasionally administered to 
break up a "cold," and to produce rapid diaphoresis. While in the 
bath the patient 's head should be kept cool by an ice bag. 

Shower Bath. — Cold shower baths are generally given for their stim- 
ulating effect. Hence, they are of great value in nervous affections, 
such as neurasthenia ; in enuresis, and as a general tonic. For these 
purposes one shower (shock) at a time is sufficient. The shower bath 
should be followed by active friction. 

Aspersion Bath. — The value of cold water dashed suddenly over the 
frame or directed in a steady, broad stream upon some particular part, 
is very great. The cases in which such a mode of treatment is bene- 
ficial are numerous. The following are a few of the more important : 
Where the muscular power of a leg or arm is impaired from long inaction, 
as in cases of fracture, dislocation, sprains and partial paralysis. The 
patient sits in a bath tub or on the floor and the operator, standing 
on a table, directs the stream of cold water upon the affected part from 
a watering can from which the sprinkler has been removed. This mode 
of treatment is rendered particularly serviceable if the circulation is 
quickly restored by vigorous dry friction for several minutes. It is also 
efficacious in systemic poisoning from drugs, suffocation from noxious 
gases, etc. 

M e die at eel Beiths. — Aside from the natural mineral baths obtained 
in the celebrated spas, which will be discussed later, a number of arti- 
ficial baths are commonly used in the treatment of diseases of infancy 
and childhood. The efficacy of these baths is, in the majority of in- 
stances, probably due to the effects of heat or cold and friction employed 
with the nonmeclicated bath. 

Nauheim Beiths. — These baths are used chiefly in the treatment of 
chronic heart disease, and diverse neuroses. "Where natural springs are 
not within reach, the baths may be prepared by the addition of the 
following ingredients which evolve carbonic acid gas; the therapeutic 
action depends chiefly upon its stimulating effect upon the skin. 

Sodium Chloride -i lbs. 

Sodium Bicarbonate Vi " 

Calcium Chloride 4 ' l 

Hydrochloric Acid 1 ' * 



92 DISEASES OF CHILDREN 

The hydrochloric acid is added gradually after the other ingredients 
have been thoroughly dissolved in the bath. The baths should be taken 
two or three days in succession, followed by a respite of two days. 

Aromatic Bath. — About six ounces each of chamomile flowers, calamus 
roots and peppermint leaves are tied up in a muslin bag and thrown into 
a warm bath. Aromatic baths are recommended in marasmus, infantile, 
spinal and other forms of paralysis, in sclerema, etc. 

Bran Bath. — Two or three pounds of wheat bran are boiled for about 
an hour in about three quarts of water. The decanted liquid is added 
to the bath. It is useful in intertrigo, eczema, pemphigus, lichen, 
strophulus, etc. 

Malt Bath. — A few ounces of malt extract are added to the bath. 
Malt baths are recommended in rachitis, spasm of the glottis, and in 
general debility. 

Mercurial Bath. — This form of bath is employed as an adjuvant in 
the treatment of syphilis. It is usually prepared by the addition of 
20 to 30 grains of calomel, or 0.5 to 1.0 grams (7 to 15 grains) of bi- 
chloride of mercury. 

Mustard Bath. — Two or 3 ounces of mustard are dissolved in a few 
pints of tepid water and added to the bath, or the mustard powder 
is tied up in a bag and thrown in the tub. The temperature of the bath 
may vary between 100° F. to 106° F. It may be administered in the 
form of a sitz bath or full bath. The patient should remain in the bath 
for from three to ten minutes. Mustard baths are indicated in collapse, 
shock or heart failure from any cause, in sudden congestion of the 
lungs or brain, etc. 

Sea Salt Bath. — About 2 pounds of sea salt are dissolved in the bath 
of 4 or 5 gallons of water. It is stimulating in its effects, and useful 
in rachitis, various forms of paralysis, etc. 

Soap Bath. — This form of bath is employed in the treatment of pru- 
rigo, lichen, strophulus, scabies, etc. It is prepared by the addition of 
from 3 to 6 ounces of soft green soap to 5 gallons of water. 

Sulphur Bath. — Half to one ounce of potassium sulphuret should be 
added to each bath. In some cases the addition of about 3 ounces of 
animal gelatin is of advantage. Sulphur baths are deserving of rec- 
ommendation in rheumatism, eczema, prurigo, urticaria, lead poisoning, 
etc. 

The Internal Use of Water 

The benefits derived from the internal use of water are mani- 
fold, but unfortunately greatly underestimated. Water taken by 
the mouth in moderate quantities — large amounts weaken diges- 



PREVENTION AND CONTROL OF DISEASE 93 

tion — cleanses the alimentary canal, stimulates peristalsis and pro- 
duces diuresis and diaphoresis. To a certain extent it acts also 
as a food. In acute diseases associated with anorexia the free 
use of water will often sustain life for weeks. In febrile diseases 
water not only quenches thirst, but aids also in the reduction of tem- 
perature. Water stimulates expectoration, and in the form of cracked 
ice checks vomiting. For the latter purpose small sips of hot water 
are sometimes resorted to. 

Lavage. — Stomach washing in children is performed in the same man- 
ner as in adults. Its field of usefulness, however, is much wider. It is 
invaluable in cases of acute, simple and toxic gastritis, pyloric stenosis, 
cholera infantum, chronic indigestion and difficult feeding. A funnel 
with a few feet of rubber tubing, to which a soft rubber catheter (No. 
12 or 14) is joined by means of a glass cannula, is the best apparatus for 
stomach washing. About 10 inches of the catheter should be passed be- 
yond the lips. The temperature of the irrigating solution should be 
about 100° F., or higher, if special indications arise. The quantity of so- 
lution to be instilled varies with the capacity of the child's stomach. 
Generally, pure, boiled water answers all medicinal purposes, except in 
poisoning, in which instance antidotes may be employed. In hyper- 
acidity of the stomach bicarbonate of soda or lime water may be added. 
Lavage is contraindicated in heart disease and hemorrhagic diathesis. 

Irrigations. — The action of irrigations is chiefly mechanical. They are 
indispensable in the treatment of divers affections of the lining mem- 
branes of internal cavities. In chronic cystitis, for example, washing 
of the Madder by means of sterile or medicated (boric acid, silver ni- 
trate) water will often rapidly effect a cure. 

Irrigations of the vagina are frequently employed in vulvovaginitis. 
A slow current of water should be employed, permitting the fluid to 
return without injury to the adjacent parts. A fountain syringe with 
a small, sterile, soft rubber catheter attached, generally suffices for 
ordinary purposes. The water bag should be suspended about 2 feet 
above the child's body. 

Irrigations with warm, sterile water are very beneficial in ear affec- 
tions, such as impacted cerumen, foreign bodies in the external audi- 
tory meatus and in otitis media. 

In febrile diseases, adenoids, chronic pharyngitis, etc., instillations of 
weak salt water or ichthyol solutions prevent and cure affections of the 
nasopharynx and ear ; it often also relieves reflex cough and embarrassed 
respiration. Instillation may be performed by means of a teaspoon or 
dropper, and should be repeated at least twice a day. 



94 DISEASES OF CHILDREN 

Copious irrigations of the mouth with sterile or medicated (silver ni- 
trate, hydrogen peroxide) water are invaluable in the treatment of 
grave forms of stomatitis. 

Enterochjsis. — The indications for low enemas are too well known to 
need further discussion. It may be mentioned, however, that in habit- 
ual constipation only small quantities of water should be injected into 
the bowel. Large quantities are apt to produce atony of the colon by 
overdistention and thus aggravate the disease. 

High enemas are given by means of a flexible (colon) tube and a foun- 
tain syringe. High enemas not only remove effete material from the 
intestines, but by using water at a temperature of 80° to 90° F. also 
reduce temperature. Hence, they combine two therapeutic measures, 
which are of signal benefit in all gastrointestinal disorders, peritonitis, 
typhoid, etc. Soap suds, bicarbonate of soda, turpentine, starch and 
salt, among other adjuvants, may be added according to indications. 

Saline injections stimulate the kidneys and promote elimination of 
putrid material. They stimulate the circulation and supply the 
deficiency of body fluids in conditions associated with an excessive 
drain of fluids. Saline injections are, therefore, a sovereign remedy in 
uremia, typhoid fever, scarlet fever, smallpox, measles, diphtheria, 
eclampsia, anemia, hemorrhages, and in shock after surgical operations, 
etc. 

A physiologic (0.9 per cent) salt water solution at a temperature of 
from 100° to 110° F. is generally used. It should be injected slowly 
through a colon tube, and continued for from fifteen to twenty minutes, 
or by Murphy-drip for several hours in succession. 

Saline injections are contraindicated in chronic kidney disease, the 
salt acting as an irritant. 

Hypodermoclysis. — Subcutaneous injection of salt water (110° F.) is 
performed by means of an ordinal fountain syringe with an antitoxin 
syringe needle attached. The syringe needle and skin should be ren- 
dered aseptic. The injection should be made in places where there is 
an abundance of subcutaneous cellular tissue ; for example, the anterior 
surface of the abdomen and thorax. The current should be very slow, 
and the quantity of the saline solution to be injected should vary be- 
tween from 2 to 6 ounces, according to age and indications. Hypo- 
dermoclysis is of inestimable value in cases of collapse resulting from 
hemorrhage; in pneumonia; uremia; acute gastroenteritis with great 
loss of body fluids ; and in leukemia. In infants it should be preferred 
to intravenous infusion. More recently good results have been reported 
from intravenous infusion by the longitudinal sinus route and by peri- 
toneal injection. 



PREVENTION AND CONTROL OP DISEASE 95 

Intrasinus Injection. — In an infant with open fontanel this offers the 
best means of introducing fluid into the blood stream. The method was 
first studied by Tobler and was introduced in this country only a few 
years ago by Helmholz. By this technic, the fluid can be injected 
through the anterior fontanel directly into the superior longitudinal 
sinus. As the sinus lies from 2 to 5 mm. from the skin, it can be 
easily entered if the fontanel is not closed ; at the posterior angle of the 
fontanel the sinus is wider and deeper. The child is held prone on the 
table by an assistant, while the needle is introduced in the median line 
just in front of the posterior angle. If the child is quiet, it is very easy 
to withdraw blood or to introduce fluid; by means of a Luer syringe, 
rubber tubing and a threeway cock any amount of fluid can be given 
without removing the syringe. The needle should be short, and the long 
point usually found on intravenous needles should be filed away. If a 
glass syringe is attached before introduction of the needle, constant 
suction may be maintained for the purpose of discerning when the sinus 
is entered. If negative pressure is not produced, blood will not flow so 
quickly, while the operator may push the needle through the inferior 
wall of the sinus, blood flowing only when the needle is withdrawn. This 
accident may also be avoided if the needle be introduced at an angle, 
directed backward. 

Any solution adapted to intravenous administration can be given in 
this way; with physiologic sodium chlorid, glucose and other mild solu- 
tions there is practically no danger. It is also an excellent method for 
transfusion of citrated whole blood in infants. 

In cases with a closed fontanel, the external jugular or femoral vein 
can often be used successfully. 

Intraperitoneal Injection. — This was first used in St. Bartholomew's 
Hospital and was introduced in this country by Howland. As may be 
noted from the following observations of J. Aikman (Rochester, N. Y.-)* 
its method of application is very simple. 

The instruments needed are a medium-sized intravenous needle, an 
infusion bottle and rubber tubing. The skin of the abdomen is carefully 
sterilized with tincture of iodin and alcohol. The skin and subcutaneous 
tissue are picked up between the thumb and forefinger, and the needle 
is introduced in an upward direction through the abdominal wall in 
the midline just below the umbilicus. Care must be taken to avoid pierc- 
ing a distended bladder, and while there is also danger of puncturing 
the intestine, no record of this accident has come to his attention. In 
cases in which necropsy was performed there was found a small hemor- 



L (Jour. Am. Med. Assn., lxxiv, No. 4, 1920.) 



96 DISEASES OF CHILDREN 

rhagic area in the abdominal wall and peritoneum, but no injury of 
serious importance. 

When the needle has passed into the peritoneal cavity, the solution 
is introduced by gravity. At first he used a Luer syringe ; but later he 
found it much easier to employ the infusion bottle. He has always used 
warm physiologic sodium chlorid solution, of which from 100 to 250 c.c, 
in older children from 300 to 400 c.c, may be given every twelve to 
twenty-four hours, in fact, if no untoward signs develop, fluid may be 
given until the abdomen becomes slightly distended. However, the in- 
jection must be made slowly in all cases, and overdistention of the ab- 
domen must be avoided. After the operation, the abdomen is covered 
with a sterile dressing. It has been shown by the phenolsulphonephtha- 
lein test and by necropsy that from 40 to 60 per cent of the fluid is ab- 
sorbed in one hour. The remaining solution acts as a reserve, the gradual 
absorption of which explains the more protracted improvement as com- 
pared to results obtained by other methods. 

He had used the other methods at the Infants Summer Hospital, but 
this year he chose the intraperitoneal route for children who had lost 
large amounts of fluid by vomiting and diarrhea. It proved superior to 
all other methods because of the ease and rapidity of administration, the 
volume of fluid that can be given at one time, and the certainty that no 
fluid will be lost. The results from this treatment are remarkable ; and 
although it has been used only in the most serious cases, the results have 
been most satisfactory. 

The fluid carried the child over the critical days until the bowel con- 
dition began to improve. He had never before seen a child recover as 
quickly after so long and severe an illness. The recovery is evidence of 
the value of this method of treatment and of the safety with which re- 
peated injections may be made through the abdominal wall. 

Electricity 

Electricity as a remedial agent in the treatment of diseases of chil- 
dren is employed in the following forms, in order in which they are 
named: Galvanic, faradic and static. 

The Galvanic Current. — The effect of the galvanic or direct current on 
the muscle is to produce contraction. The contraction takes place at 
the moment the current is closed or opened (make or break). The gal- 
vanic current, if applied by means of two electrodes along the course of 
a motor nerve, produces a uniform contraction of the entire muscle sup- 
plied by that nerve. The reaction produced by the constant current upon 
the sensory nerve varies according as the application is made with the 
positive or negative electrode, the anode being sedative in its effects, the 



PREVENTION AND CONTROL OF DISEASE 97 

cathode stimulating. A constant current of suitable strength — 10 to 
15 milliamperes — passed through living tissues causes, at the point of 
contact of the anode, an accumulation of oxygen, chlorine and acid; 
coagulation and shrinking of the exposed tissue — positive electrolysis. 
On the other hand, if the cathode is brought in contact with living ani- 
mal tissue, hydrogen and the alkalies are set free, and liquefaction of 
the parts adjacent to the electrode takes place — negative electrolysis. 

The Farad ic Current. — The faradic or induced current causes contrac- 
tion of muscles and nerves and is very effective in producing muscular 
massage. It stimulates nerve action and nutrition, excites secretion, 
and arouses latent physiologic function. 

The Static Current. — The static current produces vivid and persistent 
contraction of a large group of muscles with a minimum of pain. The 
second prominent characteristic of this current is its power of relieving 
pain. The same applies to the ultra violet rays. 

The following rules should be borne in mind : 

1. Alwaj^s administer the weakest possible current that will cause mus- 
cular contraction. 

2. Never employ electricity in the inflammatory stage of organic dis- 
ease. 

3. In applying electricity to muscles always endeavor to reach sepa- 
rately the electromotor points. In deep-seated muscles the current 
should be applied along the course of the nerves supplying them. 

4. Each electric treatment should last no longer than twenty minutes, 
and no one muscle should be subjected to the currents for more than 
three minutes. 

The indications for electricity in the treatment of diseases of children 
are practically the same as in adults. The discussion of the subject 
will, therefore, be limited to diseases in which electricity is of un- 
doubted value. 

Chronic Constipation. — The galvanic or faradic current may be used. 
One electrode is passed successively over different portions of the abdom- 
inal wall, and the other electrode is placed upon any other part of the 
body. The electric treatment should be continued for a long period. 

Diphtheritic Paralysis. — In this condition, faradization of the respira- 
tory muscles, particularly of the diaphragm, is of some service. It 
should be used in attacks of respiratory failure and continued while 
they last. 

Enuresis. — The broad anode is placed over the lumbar region of the 
spine and the small cathode over the region of the bladder or upon the 
perineum, allowing quite a strong galvanic current to act for from two 
to four minutes. Sometimes faradization proves effective. The wire 



98 DISEASES OF CHILDREN 

end of the conducting cord, connected with the negative pole, should 
be introduced into the urethral orifice for from 1 to 2 cm. and quite 
a strong faradic current allowed to act for from one to two minutes. 

Facial Paralysis. — This form of paralysis is greatly benefited by a 
weak stabile galvanic current. It should be employed four to six times 
a week, for from two to three minutes at a time. The anode should be 
placed in the auricular fossa and the cathode placed behind the ear 
while the different nerve branches and the muscles are slowly stroked 
with the cathode. In later stages faradization also is of service. 

Hysteria. — The vague disconnected symptoms of hysteria call for gen- 
eral electric treatment, and no form of electricity so advantageously com- 
bines tonic and sedative effects as the static current. A mild current 
should be employed. Two or three treatments a week will generally 
suffice. Galvanism and faradism also are of service, especially in hysteri- 
cal contractures. 

Multiple Neuritis. — The application of electricity to the affected mus- 
cles is important in order to maintain their nutrition. It should be 
begun after the acute stage has passed, that is, at the end of from three 
to four weeks. A moderate faradic current may be used if the muscles 
respond to it; otherwise a voltaic. The electricity should be applied 
daily by means of large electrodes, so that the current may reach as 
much muscular tissue as possible. The current should be strong enough 
to produce visible contraction of the muscles. 

Poliomyelitis. — The galvanic current gives the best results. It should 
not be employed earlier than the third or fourth week. A large, flat 
electrode, well moistened in salt water, is placed upon the spine over 
the affected region and the muscles were repeatedly stroked by means of 
a small electrode. The current should be of such strength as will produce 
visible contraction of the muscles, without, however, causing severe 
pain to distress the child. 

Rheumatism. — The sequelae of rheumatism, atrophy and contractures 
often call for electric treatment. The galvanic, faradic or static cur- 
rent may be employed. It is sometimes advantageous to use the gal- 
vanic and faradic currents at one sitting. The treatment should be 
repeated at least every alternate day and continued for several months. 
In muscular contracture the anode should be placed over the portion 
of the spine governing the contracted muscles and the cathode over 
the muscles themselves. For the relief of pain the positive pole should 
be applied to the most painful spot. 

Tetany. — Electric treatment has been followed by improvement in a 
number of cases. The stabile galvanic current should be employed: 



PREVENTION AND CONTROL OF DISEASE 99 

the negative pole to the spine and the positive to the irritable nerve 
trunks. 

Torticollis. — A weak galvanic current is frequently very serviceable. 
The positive pole should be placed jnst below the occiput and the nega- 
tive pole allowed to act npon the contracted muscles for from five to 
ten minutes. 

The indications for electrolysis are identical with those in adults. 

Massage 

Massage is a mechanical form of treatment consisting of intelligent 
manipulations of the superficial parts of the body. It is intended to 
produce changes in the local and general nutrition, action and other 
functions of the body. 

Indications. — Massage is indicated in hysterical, paralytic, rheumatic 
and traumatic contractures of joints; in fractures, to hasten absorption 
of callous masses ; in chronic glandular enlargements ; in swellings asso- 
ciated with rheumatism, sprains, contusion, etc. ; in torticollis, to relax 
muscular contraction; in constipation, atonic dyspepsia and gastric di- 
lation; in all forms of muscular atrophy or dystrophy; as a general 
stimulant in cases of prolonged muscular inactivity, whether from in- 
dolence, disease, feebleness (rachitis) or prolonged use of splints or 
braces, or other cause ; in various forms of paralysis, to improve the nu- 
trition and function of the affected muscles. 

Contraindications. — Massage is contraindicated in children suffering 
from gonorrheal rheumatism or peliosis rheumatica; in tuberculous, ty- 
phoid or syphilitic ulcerations of the intestines ; in acute peritonitis, ap- 
pendicitis, gastroenteritis, gastric ulcer; in tubercular glandular en- 
largements. 

Massage generally includes the following principal manipulations: 

Effleurage or Stroking. — In making the strokes both hands are em- 
ployed. The limb is grasped with one hand just above the other, in 
such a manner that pressure is exerted to some extent by the whole 
palm, but especially the ball of the thumb and the inner surface of the 
last two phalanges of the fingers. The strokes are delivered in the 
form of an ascending spiral, the two hands being moved simultaneously 
in opposite directions, the lower following closely upon the upper. The 
strokes must be made with great regularity. Light stroking has a 
soothing influence; heavy stroking stimulates the superficial structures, 
increasing the arterial, venous and lymphatic circulation. 

Friction. — This manipulation is performed with the fingertips and 
consists of firm circular, semicircular, or to and fro movements. It is 



100 DISEASES OF CHILDREN 

usually combined with effleurage and is intended to promote absorption 
by the veins and lymphatics. 

Petrissage or Kneading and Pinching. — In kneading the endeavor of 
the operator is to pick up the individual muscle or muscle groups be- 
tween the fingers of the two hands, or in some cases between the thumb 
and finger of one hand, and then to roll and squ?eze the muscle with a 
double movement. These manipulations cause circulatory, nutritive 
and alterative changes in the muscles, tendons and organs within reach. 

Tapotement, Percussion or Tapping. — Percussion is made either with 
the points of the fingers brought into a line with one another or with 
the side of the hand and fingers. The movement should be very rapid 
and elastic. These manipulations are usually employed on muscular 
parts, such as the back of legs and gluteal regions. The effect of tapote- 
ment is similar to that obtained by petrissage. This manipulation may 
be enforced also by vibrations, that is, by rhythmic, tremulous movements 
under pressure. 

Generally, all the movements are practiced at one sitting : thus, effleur- 
age, friction, petrissage, tapotement and vibration. The treatment is 
concluded by effleurage. "While in local affections local massage is gen- 
erally sufficient to effect the desired results, it is always advantageous 
to supplement the local treatment by general massage. The duration 
of each seance varies from a few minutes to a quarter of an hour. At 
first the treatment should not last more than five minutes. No force 
should be used, and the delicate skin of the child should be spared un- 
necessary injury. It is, therefore, advisable to anoint the skin with 
boric acid vaseline, cocoanut oil or any other emollient. In young 
infants massage should be limited to general friction of the body. In 
cases of malnutrition it is a good rule to give a fat inunction daily 
after the morning bath. 

Climatotherapy 

Change of climate has from time immemorial been recognized as a 
therapeutic measure par excellence, and, fortunately, our great country 
abounds with vast mountain, seashore and inland resorts, which rival, 
if not surpass, the most celebrated spas of Europe. 

In selecting a suitable health resort, we should bear in mind not 
only the state of health and the peculiarities of the individual pa- 
tient, but also the local conditions of the particular resort, such as 
the drainage, water supply, prevalence of epidemic or endemic dis- 
eases, etc. 

The air of mountainous regions is rarefied, dry, cool, bracing and 
free from organic and inorganic impurities. It improves the action 



PREVENTION AND CONTROL OF DISEASE 101 

of the skin ; favors deeper expansion of the lungs, and correspondingly 
accelerates the heart's action, improves sleep and stimulates the appe- 
tite and the powers of assimilation. Mountain air, therefore, is par- 
ticularly beneficial in chronic disorders of the alimentary tract and 
liver; in anemia; in divers respiratory affections; in malaria; in rheu- 
matism, and compensating heart disease. 

The climate of the seashore is pure and very strong. The air is 
loaded with moisture, and comparatively free from dust particles, 
hence very beneficial to convalescents from pneumonia, pleurisy and 
empyema; also typhoid and surgical operations. It often acts almost 
specifically in acute gastroenteritis of infants. 

The surf baths are invaluable in cases of nervousness, rachitis and 
local tuberculosis. 

Dry, sheltered inland resorts are to be preferred for patients suffer- 
ing from noncompensating heart disease, severe bronchitis, chronic 
kidney disease, and all such affections as are apt to be badly influenced 
by sudden variations of temperature. 

It is often of advantage to spend part of the summer months at the 
seashore and part time in the mountains or inland resorts. Young 
children suffering from tuberculosis will, during the winter months, 
derive the greatest benefit from a sojourn in New Mexico and Arizona. 
Children over ten years old often do well in colder climates, such as 
the Adirondacks. 

Select Medication in Children 

In the practice of medicine, in contradistinction to surgery, every 
physician, I believe, passes through three well-defined psychologic 
experiences in the first few years of his momentous career. Over- 
whelmed by the enthusiasm over the infallibility of drugs as im- 
pressed upon him during his college days by the learned professor of 
materia medica, he enters the medical arena with boundless confi- 
dence in his power to cope with every phase of disease and anxiously 
awaits the opportunity to demonstrate and reap the benefit of his 
skill. In the early period of his career he may luckily find encourage- 
ment for his belief and anticipations, rarely, if at all, surmising that 
many of the cures he happened to effect were m reality only natural 
or accidental events, often based upon false premises, erroneous diag- 
noses. Lo and behold ! A few unexpected failures — and his fantastic 
dream is cruelly shattered. 

With multiplying failures the state of exultation is gradually re- 
placed by that of depression, his hyperoptimism changes into hyperpes- 
simism. His growing skepticism in the efficiency of medicines often 



102 DISEASES OF CHILDREN 

leads him to seek unalloyed self-sufficiency in one of the many fields 
of surgery. Or, if he is over susceptible to the pricking of his con- 
science, he even goes so far as to abandon his profession entirely, 
little realizing that no profession, trade or business has attained the 
millennium of righteousness and immaculate dealing with his fellow- 
men. Some physicians, although continuing to practice medicine per- 
manently, float in the "river of doubt," prescribe nostrums and place- 
bos, or fall into the trap of the polished patent medicine mercenary or 
promoter of some newly discovered, but invariably threadbare, mechani- 
cal device or manipulation, or spiritual panacea, cult or science. 

Fortunately, most of us are not so readily swayed from the straight 
path of duty by such melancholy philosophy. On the contrary, we 
continue conscientiously to minister to the sick and to strive to perfect 
our knowledge in accord with the scientific advances of modern medi- 
cine. Indeed, as with many years of hard work and careful study 
our powers of intuition and judgment improve and we acquire a higher 
degree of skill to select the most appropriate remedial measures to 
combat disease, we soon find ourselves in the happy psychic state 
of equanimity and self-reliance and content with our noble mission, 
undaunted by occasional failures and untainted by triumph, fully 
conscious of the limitations of medicine, yet perfectly confident in our 
ability to relieve suffering, to prevent disease and to prolong life. 

Those of us who believe in the therapeutic value of the drugs they 
prescribe, must first of all see to it that their patients are able to 
swallow and retain them. As a rule, adults manage by means of cap- 
sules or condiments to render medicines, disgusting in taste, either 
tasteless or at least acceptable. On the other hand, children are com- 
pelled to take the medicine as given to them, and what is still worse, 
the more they resist, the more they are subjected to anguish and dis- 
tress, nay, even to severe corporal punishment, which not rarely 
borders on serious injury. 

Indeed, it is not at all rare to find little children suffering from 
acute lung or heart disease in a state nigh to suffocation from the 
effects of prolonged and firm compression of the nostrils, and many a 
helpless child bleeds from the lips and gums and even loses a tooth or 
two in the struggle with the overzealous mother who is determined 
to force down its throat a teaspoonful of a miserable decoction, which 
was, perhaps, intended only as a placebo. There is certainly no excuse for 
such cruelty, much less so in the present state of pharmaceutical progress, 
which enables us to select and to administer the most potent drugs in 
concentrated and palatable form. 



PREVENTION AND CONTROL OF DISEASE 103 

For the sake of convenience, and in order to avoid unnecessary rep- 
etition, the usual classification of drugs in accord with their therapeu- 
tic action will here be followed. 

Digestants 

Except in combination with other drugs digestants are rarely 
needed in the treatment of diseases of children. Occasionally pan- 
creatin is indicated in starch indigestion of infants, and may be pre- 
scribed either in powder form with bicarbonate of soda or the diasta- 
tic essence, with or without a small quantity of milk of magnesia. The 
latter combination mixed with glycerine and fennel-seed water will 
be found useful in colic. The elixir digestivum compositum (N.F.) 
serves as a very palatable vehicle. 

Tonics 

The simple bitters fully deserve their striking cognomen, since they 
are surely very bitter and simple, insignificant, in therapeutic action. 
I believe that the tincture of gentian, quassia, calumba and even 
cinchona owe their trifling medicinal quality to the alcohol they 
contain. Their use in children, therefore, is hardly to be commended. 
Whenever a bitter tonic is desired, we should preferably resort to a 
minute dose of nux vomica. 

Of the so-called aromatic bitters, eucalyptol is the only preparation 
worth mentioning. Internally it may be administered in one or two 
drop doses, thoroughly mixed with honey, glycerine and mucilage, 
in case of spasmodic asthma or laryngitis, and in the same affections 
it is very useful as an inhalation, especially if combined with the 
compound tincture of benzoin. 

Quinine, which is erroneously classed among the peculiar bitters, is, 
of course, indispensable in the practice of medicine. Owing to its 
miserable taste, it is, unfortunately, not receiving as wide an applica- 
tion as it fully merits. We are all familiar with its specific action in 
malaria, but it is also a sovereign remedy in pertussis, pneumonia with 
delayed resolution, and in irregular or chronic grip. I am not pre- 
pared to say whether or not the brilliant effect in these cases is possi- 
bly due to some latent malarial disposition. Its miserable taste, as 
already stated, often precludes its administration to young children, 
for disguise it as one may, quinine will always taste after quinine 
as long as there is quinine in the mixture. Some time ago* I suggested 
the rectal administration of bisulphate of quinine, but, while this 
method works exceedingly well in hospital practice, it is not very 

*N. Y. Med. Jour., Oct. 23, 1897. 



104 DISEASES OF CHILDREN 

ideal as a routine procedure. Where prompt results are desired we do 
best by giving it by mouth. The bisulphate is dissolved in water and 
rendered at least acceptable by the addition of extractum glycyrrhizae 
and syrupus acacia?. In severe cases of malarial fever characterized 
by excessive vomiting and pronounced nervous symptoms, we have 
to resort to the hypodermic. Five grains of quinine hydrochloride 
dissolved in 15 drops of hot water forms a suitable dose and may be 
injected intramuscularly under most careful aseptic precautions, two 
or three times daily. In pertussis quinine bisulphate may be given 
in one or two grain doses every two to four hours, whereas one or 
two large doses of quinine often suffice to hasten resolution in 
pneumonia or grip. Children over five years of age can often be in- 
duced to swallow chocolate coated tablets. 

Of the numerous iron preparations in the pharmacopeia preference 
should be given to the tincture of chloride of iron, the solution of 
peptomanganate of iron, the syrup iodide of iron, and the dried 
sulphate. Iron is always useful for children and especially for infants 
fed exclusively on milk, which, as is known, is poor in iron, and the 
solution of peptomanganate of iron will be found to act exceedingly 
well in all simple anemias of infancy. The tincture chloride of iron 
is usually prescribed as a styptic and hematinic in tonsillar affections 
and is advantageously administered in one or two drop doses in com- 
bination with the tincture of myrrh, potassium chlorate and glycerine. 
This mixture adheres more or less closely to the tonsils and thus exerts 
its astringent effect upon them, often dispensing with gargles and local 
applications. The syrup iodide of iron is an ideal hematinic tonic in 
children, more especially in secondary anemias following or complicat- 
ing acute infectious diseases, rachitis and diverse forms of glandular 
enlargement. In the so-called scrofular affections it often acts almost 
specifically, more particularly if combined with codliver oil. We have 
ample reason to believe also that this preparation, in addition to local 
attention to the nasopharynx, is frequently instrumental in reducing or 
even entirely removing adenoid vegetations, and its administration 
may be highly recommended to children who, notwithstanding the 
operative removal of the adenoids, continue to suffer from persist- 
ent catarrh of the respiratory tract, and show a marked disposition 
to repeated recurrence of the adenoids. Finally, it is worth empha- 
sizing that owing to the destructive effect of liquid iron upon chil- 
dren's teeth, powdered iron with a little sugar or in tablet form should 
be given instead, whenever possible. 

The selection of a stable and palpable phosphorous preparation 
is quite a problem; hence its use in children is usually limited to its 



PREVENTION AND CONTROL OF DISEASE 105 

derivatives. The syrup of lime and soda hypophosphites will be found 
particularly beneficial in rachitis and associated affections, such as 
tetany and eclampsia infantum. It may advantageously be combined 
with syrup iodide of iron and codliver oil, which contrary to all ex- 
pectations is taken by young children with considerable delight. 

Mineral Acids 

Insufficient attention is being paid to the medicinal properties of 
mineral acids. Aside from its usefulness in anacidity the dilute hydro- 
chloric acid will be found extremely serviceable in all protracted fevers, 
such as typhoid and in tuberculosis. In anorexia of children dilute 
hydrochloric acid combined with essence of pepsin and small doses of 
mix vomica often works wonders. The dilute nitromuriatic acid in 
from 2 to 5 drops, well diluted, is indicated as a preventive of the 
so-called bilious attacks, characterized by recurrent vomiting, head- 
ache and catarrhal jaundice, and the syrup hydriodic acid is an in- 
valuable remedy in all chronic bronchial affections of children, more 
particularly in unresolved pneumonia and asthma. 

Alteratives 

Arsenic, iodine and mercury form the standard remedies of this 
group, and if given in ample doses are invariably productive of 
excellent results. The use of arsenic in children is generally limited 
to chronic blood affections and chorea. In blood diseases arsenic 
should be administered in combination with iron either by mouth or 
hypodermically where prompt action is desired. For this purpose 
iron arsenate, from gr. 14 to gr. 1, will be found particularly bene- 
ficial. From time immemorial arsenic has been lauded as a specific 
in chorea, and all of us have had occasion to corroborate this view. 
It is well to bear in mind, however, that arsenic is practically useless 
in the so-called rheumatic or infectious variety of chorea which calls 
for absolute rest in bed and salicylates, and may prove to be a very 
grave affection if procrastinated by arsenic treatment. In the neurotic 
type of chorea Fowler's solution may be pushed to its full physiologic 
effect, provided the urine is carefully watched for a possible renal 
irritation. Fowler's solution in small doses seems also to enhance 
the therapeutic value of the bromide in the treatment of epilepsy. 

Except in syphilitic affections, the syrup iodide of iron or hydriodic 
acid should be given preference to potassium and sodium iodide. More- 
over, it is worth noting that the iodide per se, i. e., without mercury 
will never cure syphilis, be it congenital or acquired. Hence, the 
sooner mercury is resorted to, the better for the patient. The iodides 



106 DISEASES OF CHILDREN 

may bo rendered more or less palatable by means of peppermint or 
orange flower water and simple syrup, or fluid extract of sarsaparilla 
and water. 

Mercury is the specific in syphilis and may be administered in chil- 
dren by inunction, fortified by protiodide of mercury internally. Five 
to 10 gr. of a 50 per cent unguentum hydrargyri in lanolin, rubbed 
in thoroughly once a day, and from 1/16 to 1/12 gr. protiodide of mer- 
cury three times daily, will show beautiful results in a very short time. 
In the beginning of the treatment it may be necessary to administer 
a few drops of paregoric daily to allay intestinal irritation. In the 
newborn with congenital syphilis we may at first order 1/10 gr. calomel 
every three hours, and follow it up with the aforementioned reme- 
dies a few weeks later. There is very rarely any occasion in children 
to use more vigorous methods of treatment. 

Antipyretics and Antirheumatics 

Water internally and externally is the best antipyretic in children. 
Whenever the temperature is ephemeral in character, as for example, in 
indigestion, tonsillitis and the like, a cold sponge or pack answers 
the purpose admirably. On the other hand, when the temperature 
is continued and recalcitrant an effort must be made to influence the 
cerebral heat center, and this is best accomplished by means of warm 
tub baths. They tranquilize the nervous system, equalize the circula- 
tion, produce diaphoresis and reduce the temperature without shock or 
depression. However, in highly nervous children, antipyretic drugs, 
such as phenacetin, antipyrin, etc., are also indicated, and if given 
in moderate doses at long intervals are perfectly harmless. They may 
be made fairly palatable in syrupus acacia? and orange flower water. 
It may here be emphasized that a moderate dose of an antipyretic 
will often promptly control an attack of convulsions in children, at 
any rate long enough until its cause has been determined and appro- 
priate remedies employed for its permanent removal. It is well to 
remember also that small repeated doses of antipyretics, more partic- 
ularly pyramidon, will frequently subdue grotesque choreic move- 
ments where the usual treatment utterly fails. The specific of salicyl- 
ates in rheumatic affections is too well known to require reiteration on 
my part. It may be noted, however, that salicylates are tolerated by 
children in larger quantities than by adults, and if administered with 
a little caffeine sodium benzoate or strophanthus are perfectly free 
from depressing after effects. On many occasions I have had the oppor- 
tunity to convince myself, as well as others, of the distinct abortive 
powers of sodium or ammonium salicylate in acute poliomyelitis. The 



PREVENTION" AND CONTROL OF DISEASE 107 

salicylates are also invaluable in all acute infectious diseases ; and 
whenever one is in doubt as to what medicine to prescribe, one will 
almost invariably strike it right by selecting this remedy. It, further- 
more, has the good quality of being palatable. 

Hypnotics, Anodynes and Antispasmodics 

The selection of pleasant hypnotics and anodynes is rather difficult, 
and perhaps fortunately so, since their effect upon the delicate in- 
fantile organism at best is more or less deleterious. Very recently 
I was consulted to see a newborn supposedly suffering from atelectasis 
pulmonum. The baby was in profound stupor, its pupils markedly con- 
tracted, its breathing from ten to twelve per minute, and pulse from 
forty to fifty per minute, barely perceptible. It refused to nurse and 
swallowed with difficulty. The family physician informed me that the 
baby had been sneezing and coughing, and to relieve the anxiety of 
the parents he had prescribed a cough mixture containing 5 minims 
of paregoric in each dose, which was administered every two hours. 
Obviously we were dealing with a case of opium poisoning. By 
promptly directing the treatment against it the infant recovered very 
rapidly. The safe dose of paregoric for children is one drop for every 
year of the child's age, and one tenth of this quantity when the tinc- 
ture of opium is prescribed. In gastrointestinal affections where an 
opiate is indicated, preference should be given to Dover's powder 
(one-tenth of a grain for every year of the child's age), because of the 
beneficial effect of the ipecac it contains; and whenever vomiting pre- 
cludes its administration, we will often find an opium suppository to 
act admirably. Where very prompt action is desired, as for example, 
in cholera infantum with profuse vomiting and purging, we may ad- 
vantageously resort to a hypodermic injection of morphine (gr. 1/60) 
and atropine (gr. 1/600). ^Morphine and atropine hypo dermic ally 
are occasionally indicated also in other acute diseases, e. g., uremic 
convulsions. In respiratory affections codeine and its similar morphine 
derivatives are the drugs par excellence. "Whenever a hypnotic is in- 
dicated, codeine added to bromide will act by far better than the newer 
coal tar byproducts. The use of spasmodics in children is somewhat 
limited. In olden times belladonna was looked upon as the sine qua non 
in pertussis. It was pushed to its full physiologic effect — until the 
child was practically blinded. We know better today. Belladonna will 
be found useful, however, in ordinary catarrhs of the respiratory tract 
with profuse mucous discharge and in rhinitis of infants when the nasal 
discharge interferes with nursing. In combination with codeine, in the 
form of suppositories, belladonna is of particular value in irritable 



108 DISEASES OF CHILDREN 

bladder, strangury and tenesmus, and also acts nicely as a palliative in 
catarrhal appendicitis, when medication by mouth is contraindicated. 
We may choose hyoscyamus instead of belladonna; in fact, there is 
no better antispasmodic and anodyne in dysuria accompanying cys- 
titis than hyoscyamine sulphate. The dose is gr.1/800 for every year 
of the child's age, dissolved in syrupus althese and water. 

Stimulants 

Practically all stimulants are unpleasant in taste and require skill- 
ful compounding to render them palatable. Glycerine and the elixir 
digestivum compositum serve best in this direction. Strychnine and 
strophanthus are indicated in almost all infectious diseases of chil- 
dren, and should be administered early rather than late. In the early 
stage of the disease the dosage, of course, should be small. Gr. 1/300 
of strychnine and m. 1 of tincture of strophanthus for every year of the 
child's age will ordinarily serve the purpose admirably. I believe it is 
a mistake to leave stimulation in pneumonia to the very end, and I 
have made it a rule to give strychnine and ammonium carbonate or 
liquor ammonii anisatus the first three days of the disease, strychnine 
and strophanthus the following two or three days, and digitalis and al- 
coholic stimulants in the last days when the cumulative effect of the 
pneumonia toxin is most apt to undermine the cardiac muscles. In ur- 
gent cases we are often called upon to add caffeine sodium benzoate and 
even adrenalin. It is always a good plan to provide the nurse with an 
ample supply of quick stimulants for an eventual emergency during the 
crisis, and I am able to assure the reader that at least in one case this 
intensive preparedness has worked wonders. About two years ago I 
was invited to see a nine year old boy suffering from grippal, so-called 
wandering pneumonia of two weeks' standing and complicated by double 
otitis media. As the patient was extremely weak and showed distinct 
signs of myocardial involvement, I suggested to the family physician to 
supply the nurse with three additional hypodermic syringes, one con- 
taining 10 drops of adrenalin, the second 5 gr. of caffeine sodium ben- 
zoate, and the third 1/30 gr. of strychnine, so as to be on guard against 
sudden heart failure. The next day another consultant was called 
and the day following a third one. This excellent clinician, in his 
laudable effort to ascertain the cause for the delayed resolution, di- 
rected the nurse to sit the boy up in bed in order carefully to exam- 
ine the posterior portions of the thorax. While doing so the patient 
suddenly flapped backward, his jaws dropped, his pupils dilated and 
his heart stopped beating, in short he seemed as dead as a doornail. 
The physicians became terrified, mortified and left the sick-room to con- 



PREVENTION AND CONTROL OP DISEASE 109 

vey to the child's parents the dreadful message of the unfortunate 
event. In the meantime the nurse recovered sufficient sense to pro- 
ceed with the simultaneous injection of the three aforementioned re- 
serve stimulants in the boy's arm. To her great delight she soon 
noted a slight twitch of his mouth and heard a faint fluttering of his 
heart, and in another few minutes the boy was himself again. Resolu- 
tion set in the following day. For a number of years past the pro- 
fession has placed a great deal of reliance on sterile camphor oil as a 
powerful stimulant, more especially in pneumonia. I have used it ex- 
tensively and am still resorting to it occasionally, but must frankly 
confess never to have been convinced of its utility and have often 
felt that the sorely tried patient ought to be spared the pain and dis- 
comfort almost invariably associated with its hypodermic adminis- 
tration. Indeed, I fear, that the needle has been recently grossly 
abused, be it in the subcutaneous injection of drugs or of an unlim- 
ited number of inert vaccines and serums, which in the majority of 
instances serve only to fill the coffers of mercenaries. It is my hope 
that these remarks will not be misunderstood. While firmly believing 
in the life saving properties of antidiphtheritic and antimeningococ- 
cic serums and the like, I cannot help but feel that the profession 
is entirely too credulous to the exaggerated threadbare claims of 
the vaccine manufacturers. In treating heart disease, it is well to 
remember that while digitalis is the indispensable remedy in chronic 
cases with "ruptured compensation," it is more or less harmful in 
acute heart disease, with compensation intact, when an ice bag to the 
precordium and small doses of codeine with or without sodium salicylate 
are indicated. 

Heart Sedatives 

If ever there be any need for heart sedatives in children, we could 
readily get along with a minute dose of morphine or its derivatives 
or possibly some coal tar product, such as pyramidon. Aconite, the 
standby of the homeopath, similar to digitalis is a dangerous drug in 
the hands of the inexperienced. The real indication for aconite is 
supposed to be sthenic fever, and there are not many children too 
vigorous while ill. However, in homeopathic closes and well diluted, 
it probably can do no harm. 

Emetics 

No great effort need be made to disguise the taste of emetics. The 
wine of ipecacuanha, requiring but small doses, should be preferred 
to the syrup, and whenever emesis is very urgent a hypodermic in- 



110 DISEASES OF CHILDREN 

jection of from gr. 1/12 to gr. 1/16 of apomorphine will prove most 
satisfactory. It is to be regretted that emetics are dropping into dis- 
use, for many a case of acute indigestion in children could promptly 
be arrested by swift emesis. It may be worth mentioning also that 
moderate doses of ipecac are invaluable in whooping cough with pro- 
longed suffocating paroxysms, thus by emesis imitating nature in 
aborting the attack. 

Expectorants 

The selection of suitable expectorants requires good judgment. 
It is useless, in fact harmful, for instance to prescribe stimulating ex- 
pectorants such as ammonium chloride or carbonate in cases of per- 
sistent coughing arising from nasopharyngeal or laryngeal inflamma- 
tion. We should rather be inclined to allay the source of irritation 
by local measures and administer a sedative to relieve the cough. 
With this object in view excellent results are usually obtained from 
daily instillation of from 2 to 5 per cent of argyrol, solargentum, or 
silvol in the nose, and the internal administration of creosote carbonate 
and codeine, well mixed with glycerine mucilage and water. On the 
other hand, when dealing with a harassing cough in acute bronchitis or 
pneumonia in which the expectoration is very adhesive and cohesive, 
scanty in amount and hard to raise, a stimulating expectorant with 
or without wine of ipecacuanha or compound syrup of squills, in the 
majority of instances will prove beneficial to the patient by assisting 
nature to rid the lungs of effete material and save the patient's energy 
in the terrible battle ahead of him. In chronic bronchitis and un- 
resolved pneumonia satisfactory results are frequently achieved from 
ammonium iodide, gr. y 2 to 1 for every year of the child's age, every 
three or four hours, or from the syrup of hydriodic acid or syrup 
iodide of iron. The iodides are very useful also in the exhausting cough 
accompanying noncompensating heart disease, and may advantageously 
be combined with digitalis and an occasional dose of some morphine 
derivative. 

Diuretics and Diaphoretics 

Water is the most palatable and, in large quantities, the most effi- 
cient diuretic in bladder affections. If given hot and sweetened with 
sugar it is also an active diaphoretic and should be given in preference 
to offensive diaphoretic mixtures, whenever possible. When drugs 
are needed, potassium acetate and citrate generally serve well both as 
diuretics and diaphoretics. Potassium citrate in combination with 
hexamethylenamin acts specifically in pyelocystitis. Considerable 



PREVENTION AND CONTROL OF DISEASE 111 

caution, however, is commended in the continued administration of the 
latter, owing to its tendency to produce hematuria. Another excellent 
preparation is sodium benzoate which forms an ideal diuretic, diapho- 
retic and expectorant in the group of symptoms frequently encountered 
in acute influenza.* Diuretics are practically useless, nay, often harm- 
ful, in acute nephritis while the urinary tubules are obstructed by 
the inflammatory changes. In such cases we do much better with ac- 
tive diaphoresis by means of packs and hot baths and intestinal flush- 
ing, to rid the system of effete material without overburdening the 
renal function. On the other hand, in subacute and chronic nephritis, 
diuretics must be resorted to whenever the excretion of urine is dimin- 
ished and a tendency towards dropsy becomes manifest. In such 
cases the liquor ferri and ammonii acetatis seems to act exceedingly 
well. If, however, the dropsy is extensive and of cardiac origin, we 
always have to fall back on digitalis and strophanthus with or with- 
out diuretin or theocin sodium. Another indication for free diuresis 
is pleurisy with effusion, especially if the medication is coupled with 
complete abstention from all fluids in the diet. Under these condi- 
tions nature seems to absorb the fluid from the pleural sac to replen- 
ish the needs of the human economy. 

Laxatives and Purgatives 

We are all too familiar with the action of castor oil, calomel and 
phenolphthalein to require any detailed discussion. Attention may 
here be directed to the fact that there is no particular reason 
for giving calomel in divided doses and bothering the child unneces- 
sarily. Any baby can stand a grain of calomel without much ado. 
Effervescent citrate of magnesia is contraindicated where there is 
a tendency to vomit, the milk of magnesia being by far preferable. 
Purgatives and hydragogues are indispensable in acute nephritis and 
dropsical effusions when the kidneys are unable to perform their func- 
tion; unfortunately, however, all these preparations are very disgust- 
ing in taste and require large quantities to produce the desired effect. 
Rochelle and Epsom salts may be rendered fairly palatable by the 
addition to a saturated solution of about a third of its quantity of 
glycerine and a few drops of aromatic spirits of ammonia. The mix- 
ture may then be administered in teaspoonful doses at frequent in- 
tervals. The infusum sennas compositum may prove useful in some 
cases, but we must see to it that it is freshly prepared. In treating 
chronic constipation of children our efforts in the direction of regula- 
tion of the diet and induction of regular habits will only too often fail, 

*Influenza in Children, N. Y. Med. Jour., June 30, 1900. 



112 DISEASES OF CHILDREN 

and we are frequently called upon to advise a suitable laxative. Malt 
extract with olive oil, or cascara, or mineral oil will answer the pur- 
pose in the majority of cases. 

Intestinal Astringents 

Most of us still recall the sad time when during the summer months 
every pharmacist was stocked up with a large exhibition of summer- 
complaint-mixtures to meet the great demands of the season. For- 
tunately, with our advanced knowledge of the causes of the summer 
diarrheas of infants and the methods of prophylaxis, there is no longer 
any excessive demand for such preparations. However, we have not 
as yet reached the millennium in infant feeding and hence are still 
called upon to prescribe the time worn, yet efficient, bismuth and chalk 
mixtures. Ordinarily I prefer bismuth subcarbonate to the subnitrate, 
and order to give the patient from 10 to 20 grains after each evacua- 
tion. In this manner the dosage is controlled in accord with the 
severity of the diarrhea. As already stated, in colitis and cognate 
affections opium and ipecacuanha w r ill be found to act most satisfac- 
torily. Dover's powder may be made palatable by the addition of pul- 
vis aromaticus. The different tannin preparations are worthy of trial 
only in chronic enteric affections, but here greater benefit will be 
derived from local treatment, more particularly daily intestinal irri- 
gations with y 2 to 1 per cent of nitrate of silver, in addition, of course, 
to an appropriate diet. Sodium bicarbonate is, of course, the, specific 
in diarrhea associated with acidosis or fat and sugar indigestion, and 
should be given in large doses by mouth as well as per rectum. 

Gastric Sedatives 

Last in line but foremost in importance are the gastric sedatives, 
since with a highly irritated stomach, when all food or medication is 
promptly ejected, even a very mild disease per se is most apt gravely 
to undermine the baby's power of resistance; hence, the importance of 
first of all settling the stomach. In the majority of instances this 
is readily accomplished by one large dose of sodium bicarbonate, let 
us say, from 30 to 60 grains in water and followed up by smaller 
quantities of bicarbonate of soda and subcarbonate of bismuth with or 
without calomel. Good results are often obtained also from the dif- 
ferent medicated waters, such as lime, peppermint and bitter almond 
water in cracked ice or 1/20 of a drop of tincture of iodine well 
diluted. In recurrent vomiting lavage is indispensable, and in some 
cases we may even have to resort to a hypodermic injection of mor- 



PREVENTION AND CONTROL OF DISEASE 116 

pliine. Of course, in all cases of severe vomiting careful attention 
must be given to its etiology, more particularly involvement of the 
appendix or brain, or acidosis. 

In administering medicines to children, it is often helpful to divide 
the full dose in several small doses, if need be, giving it drop by drop 
until the whole teaspoonful has been taken. In this manner even a most 
irritable stomach will often retain the medication, whereas it would 
otherwise reject it. 

In conclusion let me suggest the following general rules to facilitate 
the selection and administration of drugs to children: 

1. Never prescribe any medicine unless you are convinced of its 
necessity; if only a placebo is required, prescribe a palatable adjuvant. 

2. Never prescribe a medicinal preparation requiring a large quan- 
tity, when a small one of the same or an equally as useful a drug will 
do the work just as efficiently. Thank Heaven, the time is past 
when the greatness of the physician stood in direct ratio to the quantity 
of the concoction he ordered. 

3. Never prescribe a painful therapeutic procedure or a nauseous 
mixture when the patient will do equally as well — and surely much 
better — without the unnecessary pain and annoyance. 

Organotherapy 

Organotherapeutics, though still in the experimental stage, is rapidly 
assuming an enviable position in the field of specific medication. This 
is true especially of the thyroids, and less so of the suprarenals, pitui- 
tary and thymus glands. 

Their modus operandi upon the human economy — whether by regu- 
lation of metabolism, or neutralization of specific poisons — is still 
shrouded in mystery. It is definitely established, however, that they 
are all of fundamental importance to the health and growth of the 
human organism. 

From a therapeutic point of view the thyroid gland only has thus 
far met all expectations. It acts specifically in cretinism and myx- 
edema, and is very serviceable also in obesity and pachydermatoses. 
The gland may be administered fresh (in soup) or dry. The dry prep- 
arations are usually given in from l/ 2 to 3 grain doses twice daily, un- 
til the desired results have, been obtained, and in smaller quantities 
thereafter. Engrafting of the sheep's thyroid in the human body has 
met with some success. The parathyroids are generally employed (gr. 
Vw "to i/4) as adjuvant or substitute of the thyroid. 

The suprarenal solutions are used principally locally as hemostatic 
and astringent, e. g., epistaxis, rhinorrhea of divers origin. Internally 



114 DISEASES OF CHILDREN 

usually hypodermically (5 min. of a 1:1000 solution) in heart failure 
and to abort a severe attack of asthma. 

The pituitary gland is (gr. *4) highly recommended in infantilism, 
in hay fever and asthma (topically as well as internally), in diabetes 
insipidus, enuresis, and tympanites (hypodermically). 

The therapeutic application for the thymus gland is thus far lim- 
ited to pronounced anemias and marasmus. The results are encour- 
aging. 

More recently the pineal gland has been found of service in diverse 
forms of mental deficiencies, especially Mongolian idiocy (p. 718). 

Vitamines 

Vitamines are vital food substances belonging to a group of organic 
bases of unknown composition which seem to be essential to metabolism 
and the maintenance of good health and normal growth and development 
of the body. They are believed to be closely allied to hormones (pan- 
creatic secretin) and possibly also to enzymes. Some vitamines are 
soluble in water and others in fat, the latter being probably closely re- 
lated to lipoids. It is claimed that lack of vitamines forms the under- 
lying cause of rachitis, scorbutus, beriberi and pellagra, but as yet there 
is no positive clinical evidence to confirm this view, although laboratory 
experiments tend to favor it. Autolyzed yeast (see p. 517) is being used 
as a vitamine in the aforementioned affections. 



CHAPTER II 

EXAMINATION OF THE PATIENT 

AND 

SEMEIOLOGY OF DISEASE 

A successful physical examination of a child, especially of an infant, 
calls for a great deal of tact, patience, and careful scrutiny. The 
physician will do well to train his eyes at a glance to observe and to 
interpret the aspects of disease. As will be noted later, in a large 
number of diseases, the attitude, the facial hue and expression, the size 
and shape of the child or of some parts of the body and finally the aspect 
of the skin, teeth, etc., are often pathognomonic. This general survey 
is preferably made while the patient is still undisturbed, utilizing the 
same time for gathering the most essential points of information per- 
taining to the family, past and personal history of the patient. 

Family History. — Longevity of the parents, brothers and sisters; the 
diseases they suffered from, especially as to tuberculosis, syphilis (mis- 
carriages in the mother often more decisive in the diagnosis than the 
Wassermann test!), rheumatism, heart, kidney or liver disease, al- 
coholism, epilepsy, insanity, etc. 

Past History. — Degree of maturity at birth, and mode of delivery 
(instrumental or otherwise) ; condition soon after birth, particularly as 
to signs of traumatism, convulsions, asphyxia, deformity, hemorrhages, 
skin eruptions, nasal catarrh ("snuffles") ; the diseases the patient suf- 
fered from at a later period, e. g., gastrointestinal, exanthematous, pul- 
monary; otitis, rheumatism, bone affections, etc. Mode of feeding (breast 
or bottle), gain or loss of weight; time of eruption of temporary or per- 
manent teeth; the time when the patient began to sit up, stand, creep 
and walk. Peculiarities of temper, etc. 

Present History. — Age of patient. 

Mode of onset of the disease (gradual or sudden). 

Fever (continuous, remittent or irregular). 

Convulsions 1 (apparent cause; time of occurrence; duration). 

Vomiting 2 (during, after, or between meals; appearance of vomit). 

Skin eruption 3 (location, duration; desquamation). 

Diarrhea 4 (duration; frequency and appearance of the stools). 



l See page 669. 3 See page 398. 
2 See page 156. 4 See page 157. 



115 



116 DISEASES OF CHILDREN 

Constipation 5 (acute or habitual; appearance of the stools), 

Pain 6 (situation, duration; degree of severity). 

Cough 7 (duration; paroxysmal or croupy; appearance of sputum). 

Dyspnea 55 (worse after fatigue or at night; sudden). 

Cyanosis 9 (duration; mode of onset — with convulsions). 

Urinary disturbance 10 (enuresis, dysuria, suppression; appearance of 
urine). 

Disturbance of Sleep (pavor nocturnus; snoring; twitching; crying 
from "starting pain"). 

Behavior and Mental Capacity 11 (recent changes, if any). 

Condition of Special Senses 12 (defective vision, hearing, etc). 

The history taking completed, we next turn to the physical examina- 
tion of the patient. This should be systematic, preferably with the 
child entirely undressed, and if deemed necessary, should include 
inspection, palpation, auscultation, percussion, mensuration and weigh- 
ing. 

AVe usually begin with the examination of the head, noting its 
size and shape, the condition of the bones of the skull, its fontanelles 
and sutures, its attitude; facial expression and hue; condition of the 
nose, eyes, ears, mouth, lips, tongue, teeth and pharynx. 

THE HEAD 

The head is rarely normal in shape immediately after birth. The 
scalp is swollen, the bones are often displaced, and here and there 
are bruises and ecchymoses, the results of a long and painful journey. 
Within about a week, the swelling subsides, the bones adjust them- 
selves, the head becomes round or oval and smooth except for the 
markings of the fontanelles and sutures. 

The cranial circumference (fronto-occipital diameter) soon after birth 
measures about 13 inches. The skull enlarges rapidly up to six months 
old — 17 inches; then more slowly about 1 inch every year up to 
five years — 21 inches; it then remains stationary in growth up to adult 
life, when it measures from 22 to 23 inches. 

The posterior fontanelle closes by the end of the second month, the 
anterior when the infant is about eighteen months old, at the latest. 

A healthy baby is able to hold up the head when about four months 
old. 
The skull is— 

1. Asymmetrical, with depressions and protrusions, in caput succe- 



5 See page 157. 7 See page 13S. °See page 119. "See pages 705, 753. 
5 See page 118. s See page 134. 10 See page 159. 12 See pages 121, 306. 



EXAMINATION OF THE PATIENT 



117 



daneum; meningo- and encephalocele; syphilis; neoplasms; abscesses; 
oxycephalia ("sugar-loaf" head), etc. 

2. Large, in hydrocephalus; hypertrophy of the brain; rachitis. 

3'. Small, in microcephalia ; porencephalia. 
The fontanelles are — 

1. Closed late, in hydrocephalus; rachitis; cretinism; idiocy; os- 
teogenesis imperfecta. 

2. Closed prematurely, in microcephalics; atrophy of the brain. 




Fig. 6. — Hydrocephalus. 



3. Distended, in active and passive congestions of the brain, e. g., 
divers forms of meningitis ; meningismus ; hydrocephaloid, intracranial 
tumors; cerebral hyperemia. 

4. Sunken, in wasting diseases ; after great loss of body fluids ; after 
lumbar puncture. 

The cranial bones are — 

1. Soft and thin, in chronic hydrocephalus; craniotabes. 

2. Hard and thick, in syphilis ; exostosis. 



118 



DISEASES OF CHILDREN 



The sutures are — 

1. Widely separated, in hydrocephalus; intracranial tumors. 

2. Prematurely closed, in microcephalia. 

Attitude of the head — 

1. Eetracted, shaky, in general debility; macrocephalus; hydroceph- 
alus ; amaurotic family idiocy. 

2. Spasmodically retracted (opisthotonos), in meningitis; meningis- 
mus; encephalitis; apical pneumonia. 

3'. Turned laterally, in torticollis; hematoma of the sternocleidomas- 
toid muscle ; retropharyngeal abscess ; cervical spondylitis ; cervical 
adenitis; mastoiditis. 

4. Moving irregularly, in hyperpyrexia; spasmus nutans; chorea; 
habit spasm. In eruptions of the scalp attended by severe itching. 



Fonticulus 
^occipitalis 



Sutura 

lambdoidea 




Tuber fronfale 



5utura frontalis 
Fig. 7.— Fontanels. (Leo-Wolf.) 



The Face 
Facies dolorosa — 

1. Face of continuous pain (eyes open, face wrinkled, mouth half 
closed and drawn to one side; moaning and whining) in divers acute 
inflammatory diseases, e. g., pneumonia, pleurisy, rheumatism, appendi- 
citis. 

2. Intermittent pain (face distorted, red, perspiring; loud crying, toss- 
ing, kicking), in colic, dysuria, etc.; vertebral caries ("starting pain"). 
Facies luctuosa — 

Face of sorrow (forehead and face wrinkled, face pale, emaciated, 
indifferent, apathetic, eyes half closed), in chronic wasting diseases, 
especially tuberculosis, and last stage of heart disease. 



EXAMINATION OF THE PATIENT 119 

Facies anxiosa — 

Face of anxiety (eyes glistening, congested, red or livid, and per- 
spiring; alas nasi active), in orthopnea from various causes, e.g., 
laryngeal stenosis, extensive pneumonia, pulmonary edema ; in hysteria. 

Facies hippocratica — 

Face of grave abdominal distress, or extreme exhaustion (face pale, 
contracted, cornea? dull, eyeballs and temples deeply sunken, nose 
pinched, lips dry, cyanotic, and covered with sordes), in moribund 
state, collapse, cholera nostras, peritonitis, etc. 

Facies meningitidis — 

Face of internal convulsions (staring look into distance, glassy cor- 
neas, rapidly changing complexion of the face), in meningitis; severe 
eclampsia. 

Facies senilis — 

Face of extreme old age (shriveled fascial muscles and skin, pointed 
nose, lusterless eyes), in marasmus; syphilis; chronic hydrocephalus. 

Facies idiotes — 

Face of the mentally defective (senile features, open mouth, pro- 
truding tongue), in all forms of idiocy and imbecility; less marked 
in adenoids. 

Facies sardonica* — 

Face of facial muscular spasm (peculiar "grin," proboscis-form 
mouth, sometimes foamy), in tetanus and similar prolonged convul- 
sive conditions. 

Facial hue** — 

1. Livid, in congenital and acquired heart disease ; in pronounced res- 
piratory difficulty, e. g., laryngeal stenosis, pulmonary edema, asthma, 
etc.; in cerebral hyperemia; sinus thrombosis; in "holding the breath." 

2. Pale, in anemia ; in acute and chronic wasting diseases ; sudden 
pallor, in collapse, e. g., from exhausting hemorrhage. 

3. Waxy, in chronic malaria ; suppurative processes ; chronic nephritis ; 
malignant disease. 

4. Yellow, in icterus neonatorum or catarrhalis, congenital oblitera- 
tion of the bile duct; in Buhl's or Winkel's disease, in liver affections, 
especially due to syphilis. 

5. Purplish, in phthisis pulmonalis ("hectic flush"), hyperpyrexia; 
pneumonia; compensating heart disease. 

6. Greenish, in chlorosis. 



*See also ''Facial Paralysis," "Facial Hemiatrophy," "Pertussis," "Nephritis," "Trichiniasis," 
p. 426, "Hemiplegia." 

**See also "Exanthemata" and "Skin Diseases." 



120 DISEASES OF CHILDREN 

7. Copper-color (e.g., on forehead), in syphilis. 

8. Bronze color, in Addison's disease. 

The Eyes 
The eyelids are — 

1. Edematous, without local inflammation, in anemias; heart and 
kidney diseases; pertussis; trichiniasis. 

2. Crusty, red and swollen, in acute and chronic inflammation of the 
eyelids; in pediculosis of the eyelashes; in congenital sj-philis (in con- 
junction with rhagades at the canthi, and purulent nasal discharge), 
in scrofulosis (with keratitis, excoriation of the upper lid, and adeni- 
tis) ; red and watery, in nasal catarrh, hay fever, and measles. 

3. Retracted, inability to lower upper lid, from loss of power in the 
palpebral muscles, in facial paralysis. 

4. Drooping (ptosis) of upper lid, from inability to raise it, in 
congenital defects of the palpebral levators or their nerve supply, 
in local trauma ; in oculomotor paralysis ; ophthalmoplegia (unilateral) ; 
encephalitis lethargica. 

5. Spasmodically contracting, in local inflammatory processes of the 
lids; in photophobia; in spasmodic affections, such as chorea and tic. 

The eyeballs are — 

1. Congested, in inflammatory processes of the eye, e.g., keratitis; 
in meningitis; asphyxia. 

2. Protruding, in exophthalmic goiter; in neoplasms (gumma); in 
chloroma (frog-like appearance). 

3. Immobile, partially or completely, in ophthalmoplegia (unilateral), 

4. Turned laterally (strabismus) ; in errors of refraction; in paralysis 
of the abducens (convergent strabismus) ; in paralysis of the oculomo- 
tor (divergent strabismus — with ptosis, mydriasis, and diplopia). 

5. Oscillating (nystagmus), in hereditary ataxia; lesions of the cor- 
pora quadrigemina ; multiple sclerosis; meningitis; sinus thrombosis; 
hydrocephalus. 

The pupils are — 

1. Contracted, unilaterally, in paralysis of cervical sympathetic, e. g., 
migraine, cervical rib (may also be bilateral), in pressure by central 
tumor. Bilaterally, in affections of the cervical cord, both sides; early 
stage of meningitis ; from the effects of opium and its derivatives, chloral, 
pilocarpine, physostigmine, etc. 

2. Dilated, unilaterally, in irritation of the cervical sympathetic, e. g., 
migraine ; in oculomotor paralysis. Bilaterally, in marked dyspnea ; 
collapse; from the effects of atropine, belladonna, hyoscyamus, cocaine, 
etc. 



EXAMINATION OF THE PATIENT 



121 



3. Unequal, in unilateral contraction or dilatation, as aforementioned ; 
in unilateral pontine lesion, and in apoplexy. 

4. Immobile, in adhesions of the iris to the lens; in eclampsia; in le- 
sions of the corpora quadrigemina ; in tabes dorsalis (immobility to light, 
but responding to accommodation- — Argyll Kobertson pupil). 

Vision is — 

1. Diminished, in errors of refraction; miosis; mydriasis; hysteria; 
acute eye affections, e. g., iritis, retinitis, etc. ; in corneal opacities, cata- 
ract, etc. ; congenital eye defects, e. g., albinism, cataract, irideremia ; in 
toxic amblyopia, e. g., overdoses of quinine, tobacco ; congenital amblyo- 
pia (usually unilateral) ; optic neuritis. 

2. Lost, temporarily or permanently, in uremic, diabetic, or other 
forms of toxemia ; in severe convulsions of central origin ; congenital 




Fig. 8. — Diagram of the visual tract. X. Lesions producing nasal hemianopia. L. 
Lesions producing lateral hemianopia. T. Lesions producing temporal hemianopia. 

complete cataract; amaurotic family idiocy (gradual onset) ; in embolism 
of the central retinal artery (unilateral) ; local injuries; optic atrophy. 

3. Double (diplopia), in peripheral palsies of the eye muscles, e.g., 
after diphtheria, influenza, herpes zoster ophthalmicus (unilateral) ; in 
strabismus. In orbital palsies, through outside pressure, e. g., neoplasms. 
In central palsies (affecting the eye on the opposite side). In nuclear 
palsies, e.g., of the abducens (involving the eye on the same side). 

4. Half, i. e., blindness of one-half of the visual field (hemianopsia) ■ 
lateral or homonymous, in lesions of the optic tract between chiasm and 
cortex; temporal, in disease of the optic chiasm affecting the anterior 
or posterior angles; nasal, in disease of the chiasm affecting the outer 
angles (Fig. 8). 



122 DISEASES OF CHILDREN 

The Ears 

Abnormalities of the ears and adjacent structures — 

1. Asymmetry of the ears, in congenital, mentally defectives. 

2. Tumefactions, at and about the ear, in the external meatus, in 
furuncles, abscesses, and local traumatism. In front of the ear, in 
epidemic parotitis (often bilateral, though not simultaneously) ; in 
secondary parotitis (complicating diseases of the mouth, local infec- 
tion in the vicinity ; acute infectious diseases, e. g., typhoid ; in new 
growths. Behind and downward, pushing the auricle forward, in mas- 
toiditis ; in perforating abscesses of the external auditory canal ; in pre- 
auricular lymphadenitis; and much less marked in glandular fever. 

Hearing is — 

1. Diminished, at a distance, but not by bone conduction, in ex- 
ternal and middle ear disease, in occlusion of the auditory canal by 
foreign bodies, e. g., cerumen, furuncles ; or outside tumors, e. g., paro- 
titis ; in nasopharyngeal disease, e. g., adenoids. 

2. Lost, temporarily or permanently, both at a distance and by bone 
conduction, in congenital defects of the auditory apparatus; in com- 
pression (by intracranial tumors) or atrophy of the auditory nerve; 
in disease of the pons or cerebellum which has spread to the fourth 
ventricle; in amaurotic family idiocy. 

3. Disturbed by noises (tinnitus aurium), in foreign bodies in the 
auditory canal, e. g., cerumen, mycosis, myringitis ; in catarrh of the 
Eustachian tube; in otitis media; neuroses; epilepsy, and mental affec- 
tions. 

The Nose 

Abnormalities of the nose in structure and function — 

1. Saddle-shaped, sunken, in hereditary syphilis ; in traumatism, 

2. Compressed and pointed, in nasal obstruction, chiefly adenoids. 

3. Pinched and pale, in collapse; sudden fright; phthisis pulmonum. 

4. Purplish in color, in circulatory and respiratory difficulties, e. g., 
pneumonia, heart disease. 

5. Hyperactivity of the alse nasi, in grave dyspnea. 

6. Nasal voice or cry, in nasal obstruction, e. g., adenoids, rhinitis, 
retropharyngeal abscess; in diphtheritic paralysis; in ulceration of the 
nasal bones, especially in syphilis. 

Nasal discharge — 

1. Serous, transparent, later mucous, in acute simple rhinitis 
("cold"); measles; hay fever. 

2. Serosanguinolent, later purulent, in diphtheritic, scarlatinal, and 



EXAMINATION OF THE PATIENT 123 

syphilitic rhinitis; in the presence of foreign bodies in the nose; in 
scrofulosis. 

3. Mucopurulent or purulent, in severe acute rhinitis ; in putrid in- 
fection ; in sinusitis. 

4. Hemorrhagic (epistaxis) in nasal trauma; inflammation of the 
nasal mucosa; nasal polypus; adenoids; hemophilia; vicarious menstru- 
ation; passive congestion of the brain; increased vascular tension, e. g., 
hyperpyrexia (especially if sudden, as it is apt to be at the onset of ex- 
anthematous diseases), heart and lung diseases, pertussis, influenza; 
in diseases of the blood, e. g., sepsis; leukemia, etc. 

The Lips 
The lips are — 

1. Excoriated (upper lip) from acrid nasal discharge, in acute and 
chronic affections of the nose, e.g., rhinitis, adenoids; in scrofulosis; 
syphilis. 

2. Covered by herpes, a vesicular eruption (usually the upper lip at 
the angle of the mouth) in ordinary "colds'"; in pneumonia; in menin- 
gitis cerebrospinalis. 

3. Cracked and scarified, especially at the angles of the mouth, in 
syphilis hereditaria; but also in burns (usually unilaterally). 

4. Covered by sordes, in septic infections ; in typhoid fever. 

5. Rosy in color, in good health. 

6. Deep red, in compensating heart disease. 

7. Purple, in marked dyspnea, from respiratory and circulatory dis- 
turbances. 

8. Pale, in divers forms of anemia. 

9. Livid, in heart failure. 

10. Dirty, soot-like, in sepsis; typhoid fever; ulcerative stomatitis. 

The Oral Cavity 
The mouth is — 

1. Drawn to one side, droops, in facial paralysis, especially when 
the facial muscles are brought into action; in progressive facial hemi- 
atrophy; in hemiplegia. 

2. Drawn outward and downward, with the lips pointed forward, 
proboscis-like, in trismus neonatorum, tetanus and tetany. 

3. Broad and grinning, in cretinism; idiocy. 

•4. Large from birth, in macrostomia ; small and contracted, in micro- 
stomia ; in congenital syphilis : from the effect of burns. 

5. Open habitually ("mouth-breathing") in nasal obstruction; ade- 
noids ; idiocy ; retropharyngeal abscess. 

6. Twitching, spasmodically, in chorea ; habit spasm. 



124 DISEASES OF CHILDREN 

Fetor ex ore — 

1. Stale insipid, in catarrh of the nasopharynx; dental caries; in feb- 
rile diseases ; chronic dyspepsia. 

2. Putrefactive, at short range, in divers forms of simple stomatitis; 
acute indigestion. At a distance, in noma ; malignant diphtheria or 
scarlatinal angina. 

3. Sulphuretted hydrogen odor, in fetid bronchitis ; pulmonary gan- 
grene. 

4. Acetone odor, in diabetes ; cyclic vomiting ; acidosis. 

5. Ammoniacal odor, in uremia. 

6. Chloroform, ether, alcohol, etc., odors, from the effects of these 
drugs. 

In irritable children it is preferable to postpone the examination 
of the mouth-cavity until the other portions of the body have been 
thoroughly examined, since the undue excitement usually created by 
the inspection and palpation of the mouth and throat of the patient 
greatly interferes with the study of the other physical phenomena. 
Through daily practice, the physician soon learns, almost at a glance, 
to distinguish the abnormal from the normal; until he has acquired 
this skill, however, he should examine the contents of the oral cavity 
slowly and systematically. 

The gums, teeth, floor and roof of the mouth; the tongue, buccal 
mucous membrane, the uvula, fauces, tonsils and posterior pharynx — 
all should receive careful attention. 

The gums are — 

1. "Whitish, thin, and hard, normally in early infancy. 

2. Eeddened, slightly swollen and painful to touch, before erup- 
tion of teeth. 

3'. Spongy, swollen, and prone to bleed, in divers forms of sto- 
matitis ; in scurvy ; purpura ; in other grave constitutional diseases, such 
as leukemia. 

4. Purulent, receding, from the teeth, in pyorrhea alveolaris; al- 
veolar abscess. 

5. Bleeding, without inflammatory symptoms, in hemophilia. 

6. Colored blue, forming a blue line along the margin of the gum, 
in lead poisoning. 

The temporary teeth are twenty in number, and under normal condi- 
tions generally appear in groups, at variable intervals, as follows: 

1. Two lower central incisors at the age of from six to eight months 

2. Four upper incisors (2 central, 2 lateral) from eight to ten 
months. 

3. Two lower lateral incisors from eleven to twelve months. 



EXAMINATION OF THE TATIENT 



125 



4. Four anterior molars (2 upper, 2 lower) from fourteen to six- 
teen months. 

5. Four canines (2 upper, 2 lower) from eighteen to twenty months. 

6. Four posterior molars (2 upper, 2 lower) from twenty-two to 
thirty months. 

Abnormal teething 1 — 

1. Dentitio tarda, i. e., considerable retardation (absence of a tooth 
at the age of a year or later), in rickets; general debility; congenital 
syphilis; cretinism; idiocy, etc. 




Fig. 9. — Temporary and permanent teeth. 

2. Dentitio precox is of no special significance. Occasionally occurs 
in congenital syphilis (a tooth may appear soon after birth) ; in hydro- 
cephalus. 

3. Irregular implantation, incurvation, striation and premature ero- 
sion, the same as in "dentitio tarda" (q. v.). 

The permanent teeth appear normally in the following order: 

1. Four first molars (2 upper, 2 lower) at about six years. 

2. Four central incisors (2 upper, 2 lower) at about seven years. 



126 DISEASES OF CHILDREN 

3. Four lateral incisors (2 upper, 2 lower) at about eight years. 

4. Four anterior bicuspids (2 upper, 2 lower) at about nine years. 

5. Four posterior bicuspids (2 upper, 2 lower) at about ten years. 

6. Four canines (2 upper, 2 lower) at about eleven years. 

7. Four second molars (2 upper, 2 lower) at about twelve to fif- 
teen years. 

8. Four third molars (2 upper, 2 lower) at about seventeen to 
twenty-five years. 

Abnormalities of the permanent teeth — 

1. Increased vulnerability and brittleness, in divers grave constitu- 
tional affections, e. g., rickets, profound anemia ; in neglect and injury 
of the teeth, especially by escharotic drugs for cleansing of the teeth 
or medicinal purposes (e.g., the tincture chloride of iron, acids). 

2. Asymmetry, in harelip ; cretinism and other forms of defective 
mentality; nasal obstruction; " mouth breathing"; thumb sucking. 

3. Looseness, in gingivitis; ulcerative stomatitis; mercurialism ; 
scurvy; pyorrhea alveolaris. 

4. Hutchinson's teeth, i. e., peg-shaped, dwarfed upper central inci- 
sors, notched in their cutting edge, in inherited syphilis. 

5. Microdentism, small white transparent teeth, not abnormal, but 
occasionally seen in children of syphilitic parents. 

6. Amorphism, tendency of teeth assuming abnormal shape (e. g., 
incisor taking the shape of canine) frequently in syphilis, but also in 
nonsyphilitic children. 

The floor of the mouth may present — 

1. Adhesio linguae, a frequent cause of difficult suckling; and later 
of difficult speech. 

2. Sublingual ulcer, in protracted coughing, especially pertussis. 

3. New growths, e. g., ranula, fibroma sublinguale; in salivary cal- 
culi ; inflammatory swelling. 

The palate is — 

1. Highly arched and asymmetrical, in divers forms of mental de- 
generacy; adenoids. 

2. Defective or perforated, in congenital clefts of the palate ; in 
syphilitic or gangrenous processes (e.g., diphtheria, scarlatina). 

3. Eed, velvety, in scarlatina. 

4. Punctiform or stellate, in measles or rotheln. 

5. Vesicular with red areola, in chickenpox. 

6. Papular, in smallpox. 

7. "Whitish-yellow eroded dots over the hamular process of the palate 
bone, in Bednar's aphthas. 



EXAMINATION OF THE PATIENT 



127 



8. Minute, yellowish-white milia, in "epithelial pearls" (on both 
sides of raphe near the junction of the hard and soft palates). 

9. White specks or scattered patches, in different forms of stomatitis, 

10. Hemorrhagic and punctiform, in hemorrhagic diathesis; tubercu- 
lous and cerebrospinal meningitis; pernicious blood affections. 

The buccal mucous membrane presents in addition to the discolorations 
occurring upon the palate, also the following: 

1. Brownish, greenish or gray ulcer, in incipient noma. 

2. Red spots with central, rounded, slightly elevated, bluish efflores- 
cence (Koplik's spots), in measles. 




Fig. 10. — Ulcerative stomatitis involving also the lips and adjacent structures. 



The tongue is — 

1. Large, in congenital macroglossia ; in cretinism; idiocy; glossitis. 

2. Furred, in all acute and protracted forms of gastroenteritis; feb- 
rile diseases; nasopharyngeal catarrh. 

3. Red, in scarlatina (strawberry tongue); stomatitis; glossitis; gas- 
tritis (hyperacidity). 

4. Yellow, in biliousness; liver disease; chronic intestinal indigestion. 

5. Pale, in anemia. 



128 DISEASES OF CHILDREN 

6. Gray, brown, and somewhat black, with red border and tip, in ty- 
phoid fever, in sepsis. 

7. Black, in profound sepsis, in collapse impending death. 

8. Livid, in general cyanosis; congenital heart disease; severe pneu- 
monia. 

9. Spotted, desquamating, in geographical tongue; hyperpyrexia; 
stomatitis. 

10. Fissured, in glossitis desiccans; hyperpyrexia; burns. 

11. Ulcerated, in severe forms of stomatitis ; in syphilis ; tuberculosis ; 
traumatism (biting of the tongue during an epileptic fit; irritation by 
carious teeth). 

12. Dry, in mouth-breathing; excessive thirst (e.g., hyperpyrexia, 
diabetes) ; in sepsis. 

13. Protruding, in macroglossia (e.g., idiocy, cretinism). 

14. Drawn to one side, in paralysis of the hypoglossal nerve (toward 
the diseased side) ; in peripheral facial palsy (toward the healthy side). 

15. Tremulous, in hyperpyrexia; debility; chorea; disseminated lateral 
sclerosis; bulbar paralysis. 

The saliva is — 

1. Increased in quantity, in mercurialism ; stomatitis ; teething ; 
idiotic conditions. 

2. Diminished in quantity, in fever ; from the effects of atropine, etc. ; 
parotitis; glossitis. 

The uvula — 

May be elongated ; the seat of a deposit which may extend from the 
tonsils or from the buccal mucous membrane (e.g., stomatitis). 

The tonsils are — 

1. Enlarged, in divers forms of amygdalitis; diphtheria; scarlatina; 
pharyngitis; influenza; rheumatism; abscess; traumatism; glandular 
fever; foreign bodies (e.g., calculi) ; new growths (e.g., fibrous poly- 
pus, hydatid cyst). 

2. The seat of a deposit, in follicular tonsillitis (small isolated white 
pellicles which coalesce) ; in parenchymatous tonsillitis (at first white, 
later yellowish green, resembling "point of abscess") ; in tonsillitis her- 
petiformis (vesicular deposit, ending in ulcer) ; in necrotic tonsillitis 
(yellowish-green patch) ; in influenza and pharyngitis (superficial exu- 
dation) ; in scarlatina and diphtheria (large pseudomembrane) ; in 
stomatitis mycotica (flour-like deposit). 

In doubtful cases it is imperative to examine a smear of the tonsillar 
deposit microscopically or bacteriologically. 



EXAMINATION OF THE PATIENT 129 

The Neck 

The lymphatic glands are — 

Enlarged, in all forms of angina, especially that cine to diphtheria 
or scarlet fever; in affections of the month (e. g., stomatitis, gingivitis) ; 
in parotitis; mastoiditis; rubella; glandular fever; pseudoleukemia; 
scrofulosis (tuberculosis) ; eczema capitis; local infections; nasal affec- 
tions. 
The thyroid gland is — 

1. Enlarged, in goiter, exophthalmic goiter; endemic goitrous cre- 
tinism ; thyroiditis ; temporarily, before menstruation. 

2. Atrophied or absent, in sporadic cretinism. 
Tumefactions (other than those of the glands of the neck) — 

1. Hematoma of the sternocleidomastoid, in the center or at sternal 
insertion of the sternocleidomastoid muscle. 

2. Hygroma cysticum, between lower jaw and clavicle, attains enor- 
mous size. 

3. Fistula colli congenita, at sternoclavicular articulation. 
Pulsation of the — 

1. Arteries, in heart disease; hyperpyrexia. 

2. Veins, especially in tricuspid insufficiency. 
Stiffness of neck (See " Attitude of Head," p. 118). 

THE THORAX AND ITS CONTENTS 

Auscultation and Percussion 

Auscultation is best performed by a small biaural stethoscope, since 
with this instrument every inch of the infantile thorax can be thor- 
oughly examined and small circumscribed lesions readily detected. 

Normally the respiratory sound is puerile (rough vesicular) in in- 
fancy or early childhood; and vesicular in older children. 

In auscultating the infantile lungs we should remember the follow- 
ing peculiarities: 1. During quiet respiration the inspiratory sound 
is fairly audible, while the expiratory sound is but slightly so ; hence 
to obtain more distinct physical signs it is of advantage to disturb the 
infant, or to make it cry. 2. Owing to the larger diameter of the right 
bronchus, the respiratory sounds are louder on the right side than on the 
left. 3. Pure bronchial breathing is often normally heard over the 
interscapular regions, especially to the right of the spinal column. 4. 
Adventitious sounds originating in the nasopharynx and larynx are 
frequently transmitted to the chest and may be misinterpreted as signs 
of pulmonary disease. 



130 



DISEASES OF CHILDREN 



The normal pulmonary percussion note is clear, loud, and somewhat 
tympanitic. It is somewhat metallic, when the child cries ; cracked-pot- 
like, over the right subclavicular region ; somewhat dull over the areas 
overlapping the liver, heart and spleen. 

Percussion of the infantile lungs should be practiced while the patient 
is held in a sitting posture (watch heart action!) perfectly still and as 
erect as possible. It should be performed gently, preferably during the 
height of inspiration and expiration. Every portion of the lungs should 




Fig. 11. — The thoracic and abdominal regions. 1. Hypochondriac. 

3. Inguinal. 



?. Lumbar, 



be carefully gone over, paying especial attention to the sub- and supra- 
clavicular spaces, which are not rarely the seat of consolidation, and 
the area corresponding to the tracheal bifurcation, which is often the 
seat of tuberculization of the bronchial glands. The physical signs 
are not always conclusive, if percussion is performed too forcibly (may 
give rise to covibration of the more distant parts) ; if the child cries 
(during the act of crying compression of the lungs by ascension of the 
diaphragm produces artificial dullness); if the position of the child is 



EXAMINATION OF THE PATIENT 



131 



faulty (e. g., lying on the abdomen pushes the diaphragm upward and 
compresses the kings); or if the thorax is bent sharply forward. 

In auscultating the heart we should bear in mind the following: 1. 
Accentuation of the first sound is heard equally as well at the arterial 
and venous orifices. 2. Accentuation of the second sound is ordi- 
narily not heard until about the age of puberty. 3. Both heart sounds 
are louder in children than in adults and are more widely transmitted. 
4. Reduplication of the heart sounds is not uncommon, and generally 
the result of excitement. 5. In infants hemic murmurs are rare. 6. 




Fig. 12. — The regions of the back. A. Suprascapular or supraspinatus. B. 
Scapular. C. Interscapular. D. Iufrascapular or lower dorsal. E. Lumbar. F. 
Sacral. 



The heart beat, as to frequency and rhythm, is apt to undergo great 
variations on the slightest provocation. 

Percussion of the child's heart should be performed very gently while 
the patient sits (watch heart action!) quietly and bent slightly for- 
ward. The data obtained on percussion while the child cries, holds its 
breath, etc., are not wholly to be depended upon, since during bodily 
unrest the heart is very apt to change its relation to the chest wall. 



132 DISEASES OF CHILDREN 

The same holds true in the event of the heart being overlapped by 
emphysematous lungs; or if the heart is left bare by atrophy of the 
adjacent lung portions, or by displacement or retraction of the heart 
or lungs by pleuritic or pericardial adhesions. 

THE THORAX 

The normal infantile thorax is round and somewhat cylindrical, its 
sagittal and transverse diameters being nearly equal. As the child 
grows older, the chest assumes a more conical shape, until, at puberty, 
it resembles that of the adult. The chest wall of the child is thin, 
elastic and yielding, owing to incomplete development of the muscu- 
lar and bony structures. The ribs of the infant are nearly horizontal. 
The measurements of the thorax are — 

In the newly born infant, about lSy 2 inches. 

At one year, 18 inches. 

At three years, 20 inches. 

At six years, 23 inches. 

At twelve years, 26 inches. 

At the end of the fifteenth year, the measurement of the circum- 
ference of the chest is about half of that of the body length. 

Up to about eighteen months the circumference of the chest nearly 
equals that of the head. If from the end of the second year on 
the circumference of the head exceeds that of the chest, there is a 
strong suspicion of hydrocephalus, marked rachitis and contraction 
of the chest through pulmonary disease or imperfect development (ade- 
noids). On the other hand, if the chest measurement in early child- 
hood by far exceeds that of the head, it is indicative either of an ab- 
normality of the chest, e. g., distention by fluids, or of congenital mal- 
development of the head, e. g., microcephalus, infantilism. 
Abnormal shapes of chest — 

1. Barrel-shape (deep, short and broad), in emphysema, and the 
lung affections which precede it, e. g., asthma, pertussis ; protracted 
laryngeal stenosis. 

2. Flask-shape (flat, narrow and long), in phthisis pulmonum; naso- 
pharyngeal stenosis, especially adenoids. 

3. Funnel-shape (marked depression in lower portion of sternum), in 
rachitis; Barlow's disease; also congenital. 

4. Pigeon- or chicken-breast-shape (protrusion of median portion 
of sternum and flattening of sides of chest), in rachitis; congenital heart 
disease. 



EXAMINATION OF THE PATIENT 133 

5. Unilateral bulging, in pneumothorax; pleurisy or pericarditis with 
effusion; tumor; scoliosis (opposite side). 

6. Unilateral flattening, in pleuritis retr aliens (after absorption of 
fluid); pulmonary contraction, e.g., tuberculosis; after pyothorax op- 
eration; scoliosis. 

Tumefactions — 

1. Costal, nodular, in rachitis (rachitic rosary) ; tuberculous and 
syphilitic processes; multiple exostoses. 

2. Intercostal, doughy, in suppuration of the bronchial glands; em- 
pyema necessitatis; lung hernia. 

3. Mammary, in mastitis; cold abscess; as a partial manifestation 
of parotitis ; new growths. 

Abnormal posture of scapulae — 

1. Prominent, uni- or bilaterally, "angel-wing" deformity, in con- 
genital malformation; in emaciation. Unilaterally, in scoliosis; paraly- 
sis of the scapular muscles, e. g., after local trauma ; poliomyelitis ; pro- 
gressive atrophy. 

2. Sunken, after empyema operation; in scoliosis. 
Activity of the thorax in breathing — ■ 

1. Increased, bilaterally, in asthma; laryngeal obstruction; unilat- 
erally, on the sound side, in pleurisy with effusion, pneumothorax; 
fixed deformities. 

2. Diminished, bilaterally, in emphysema ; hydrothorax ; diffuse tu- 
berculization; paralytic conditions of the chest wall; sclerema; col- 
lapse ; unilaterally, in pleurisy with effusion ; pneumothorax ; pleuro- 
dynia ; pleuropneumonia with "stitch pain." 

Pain on pressure — 

1. Superficial, in rheumatism of the chest muscles ; intercostal neu- 
ralgia ; affections of the ribs (caries, periostitis, fracture, etc.) ; local- 
ized abscesses (empyema necessitatis); and tumefactions (e.g., masti- 
titis). 

2. Deep, in pleurisy ; pneumonia ; phthisis pulmonalis. 

The Lungs" 

The lungs are normally fully distended with air within the first 
few hours of life. In the premature or delicate infant full lung in- 
flation may not occur until several weeks after birth. The lower lobes 
particularly may remain in a state of atelectasis. 

The normal boundaries of the lungs differ somewhat with the age 
of the child. On both sides they project with their summits into the 



*See "Auscultation" and '"Percussion," p. 129. 



134 DISEASES OF CHILDREN 

supraclavicular fossa 1 . From here they descend in the following manner: 
The right lung- (lower border) lies — 

In the sternal line at a point corresponding to the fifth (upper bor- 
der) rib. 

In the parasternal line at a point corresponding to the fifth (lower 
border) rib. 

In the mammary line at a point corresponding to the sixth rib. 

In the axillary line at a point corresponding to the seventh rib. 

In the scapular line at a point corresponding to the tenth rib. 

The left lung (lower border) lies — 

In the sternal line at a point corresponding to the fourth rib. 

In the parasternal line at a point corresponding to the fourth rib. 

In the mammary line at a point corresponding to the sixth rib. 

In the axilla^ line at a point corresponding to the seventh or eighth 
rib. 

In the scapular line at a point corresponding to the tenth rib. 

Posteriorly, the base of the left lung is slightly lower than that of 
the right lung. 

Number of respirations per minute — 
In the newborn, from 35 to 40. 
At the end of the first year, 30. 
At the end of the second year, 25. 
At six years, 22. 
At twelve years, 20. 

Character of respiration — 

1. Abdominal, in children under four years of age. 

2. Costoabdominal, in children (male and female) up to ten years; 
in the male, in older ones. 

3. Thoracic, in girls over ten years. 

4. Regularity of respiratory rhythm is usually not fully established 
before the age of two years. 

Abnormalities of respiration — 

1. Increased frequency, in respiratory and circulatory diseases (see 
"difficult breathing"); pyrexia; emotional excitement; compression of 
the lungs by an accumulation of gas ; fluids, or solid masses. 

2. Diminished frequency, in grave central disease; extreme weak- 
ness ; poisoning from belladonna, opium, etc. 

3. Costal breathing in boys over ten years old, and increased cos- 
tal breathing in girls, in inflammatory diseases of the abdominal and 
pleural cavities (by interference with the action of the diaphragm) 



EXAMINATION OF THE PATIENT 



135 



TERNAL LINE 
PARASTERNAL LINE 
MAMMARY LINE 




tern 



Fig. 13. — Diagnostic lines of the thorax. 




Fig. 14. — Anterior boundaries of the lungj 




Fig. 15. — Posterior boundaries of the lungs. 



136 DISEASES OF CHILDREN 

e. g., peritonitis, pleuritis ; in abdominal distention by gases, fluids, or 
solid masses ; in paralysis of the diaphragm, e. g., bulbar paralysis, polio- 
encephalitis, neuritis (postdiphtheritic) of the phrenic nerve; in drug 
poisoning ; in hysteria. 

4. Purely abdominal breathing, especially in girls over ten years old, 
in emphysema ; scleroderma ; paralysis of respiratory muscles, e. g., bul- 
bar paralysis, poliomyelitis. 

5. Irregular breathing, in conditions associated with ' ' difficult breath- 
ing " ; in cerebrospinal affections ; in atelectasis ; painful diseases of the 
respiratory muscles ; in hysteria. 

6. Stertorous breathing, in nasopharyngeal obstruction, e. g., retro- 
pharyngeal abscess, adenoids; in uremic or apoplectic coma. 

7. Cheyne-Stokes' breathing, occasionally in infants during sleep; in 
heart failure from divers causes; in meningitis, especially the tubercu- 
lous variety ; in meningeal hemorrhage, tumors or abscess exerting pres- 
sure upon the brain ; in drug poisoning, e. g., opium ; in death agony. 

8. Difficult or labored breathing (dyspnea), in laryngeal, tracheal or 
bronchial obstruction from divers causes, e. g., croup, diphtheria, large 
thymus, asthma, etc. ; in affections associated with diminution of the 
usual pulmonary breathing area, such as active or passive congestion, 
e. g., pneumonia, pleurisy or pericarditis with effusion, compression or 
displacement by neoplasms, deformities of the thorax, advanced pul- 
monary tuberculosis ; in grave circulatory disturbance inducing deficient 
oxygenation of the blood or obstruction to pulmonary circulation, e. g., 
blood or heart diseases ("cardiac asthma") ; in conditions giving rise 
to "irregular breathing" (q.v.), "stertorous breathing" (q.v.), and 
"Cheyne-Stokes' breathing" (q.v.,), in neuroses, e.g., hysteria, neuras- 
thenia — asthma hystericum. 

Abnormal respiratory sounds — 

1. Vesicular, exaggerated, in bronchial inflammation; atelectasis. 

2. Weak, in thickened pleura; moderate pleuritic effusion; emphy- 
sema. 

3. Absent, in extensive pleuritic effusions. 

4. Bronchial, over the seat of the lesion, in pneumonia; tubercu- 
lization; above the seat of lesion, in compression of the lung by tumors 
in the chest cavity or pleuritic exudates. 

5. Amphoric, in smooth-walled cavities; open pneumothorax. 
Abnormal secretory sounds — 

1. Dry, sibilant and sonorous rhonchi, in bronchitis ; asthma (wheez- 
ing and whistling). 

2. Dry, crackling, in incipient phthisis (apex) ; beginning of second 
stage of pneumonia. 



EXAMINATION OF THE PATIENT 137 

3. Moist, large and medium-sized rales, in bronchitis (larger bron- 
chial tubes) with abundant secretion; in cavities. 

4. Moist, small rales, in capillary bronchitis. 

5. Moist, crepitant (fine) rales, in croupous pneumonia (crepita- 
tio indux or redux; catarrhal pneumonia; capillary bronchitis (in con- 
junction with coarse rales); tuberculization; pulmonary edema (in 
conjunction with larger moist rales). 

6. Metallic tinkling, in pneumothorax. 

7. Metallic splashing or gurgling, in sero- or pyopneumothorax. 

8. Friction sound, in pleuritis sicca; pleuropneumonia; miliary tu- 
berculosis. It is not altered by coughing, as is the case with rales. 

Vocal resonance" — 

1. Diminished, in bronchitis with free secretion; pleurisy with ef- 
fusion ; obstruction of bronchial tubes ; emphysema ; pneumothorax. 

2. Increased, in tuberculization; pneumonia (over consolidation). 

3. Bronchophony (concentration of voice near the ear), in tuberculi- 
zation; pneumonic consolidation; compressed lung above pleuritic ef- 
fusion; bronchial dilatation. 

4. Exaggerated bronchial whisper; the same as for bronchophony 
(q.v.). 

5. Pectoriloquy (complete transmission of sound), the same as for 
bronchophony (q.v.). 

6. Amphoric voice ("the echo"), in large cavity; pneumothorax. 

7. Egophony, bleating (goat-like resonance of voice), in pleurisy with 
effusion (near upper boundary of dulness) ; pleuropneumonia ; hydro- 
thorax. 

Abnormal percussion resonance — 

1. Dull, or diminished resonance, in pneumonia ; tubercle ; neoplasms ; 
pulmonary gangrene; pulmonary abscess with thick masses; pleuritic 
thickening ; atelectasis. 

2. Flat or absence of resonance, in pleurisy with effusion; hydro- 
thorax; hemothorax. Eesonance may alter with change of patient's 
position. Also in last stage of pneumonia with extensive consolida- 
tion. 

3. Tympanitic, or drum-like, resonance, in tuberculosis (cavities) ; 
open pneumothorax; lung atrophy; above pericardial or pleuritic ex- 
udations or near neoplasms — the result of increased air pressure; pul- 
monary edema; moderate emphysema. 

4. Amphoric, metallic, or concentrated tympanitic sound, in large 



*Vocal resonance elicited on auscultation corresponds to vocal fremitus as obtained by pal- 
pation. Fremitus is increased in consolidation, and diminished in effusions. 



138 DISEASES OF CHILDREN 

tuberculous cavity with solid and tense walls lying close to the chest 
wall; occasionally heard in healthy child during crying. 

5. Cracked-pot resonance, in pulmonary cavity communicating with 
the bronchial tubes — usually in tuberculosis; may be elicited also in 
healthy child during talking or singing. 

6. Bandbox note (abnormally loud and deep), in pronounced emphy- 
sema; pneumothorax with strong tension of the chest wall. 

Cough 

It is essentially a reflex act arising from direct or indirect irrita- 
tion of the respiratory center. In a measure it can be voluntarily pro- 
duced or suppressed. The ability to cough is lost in paralysis of the 
cricoarytenoid or the respiratory muscles ; hence cessation of cough- 
ing — with plenty of mucus in the bronchial tubes — particularly in pul- 
monary disease, is considered a bad omen. The nature of the cough 
may often be decided upon from its character. 
The cough is usually — 

1. Short and somewhat hoarse, in nasopharyngeal catarrh and ade- 
noids. 

2. Loud and barking, in laryngitis and spasmodic croup. 

3. Dull, barking and somewhat moist, in ulceration of the larynx 
(diphtheria, syphilis, etc.). 

4. Dry, tight and whistling, in early bronchitis. 

5. Soft, deep, and loose, in advanced bronchitis. 

6. Paroxysmal and whooping, in pertussis and other spasmodic affec- 
tions; tuberculosis of the bronchial glands. 

7. Hemming, in incipient phthisis and in nervousness. 

8. Short, sharp and painful, in pneumonia, pleurisy, and cardiac dis- 
ease. 

9. Deep and distressing, in chronic phthisis, asthma, emphysema, 
etc. 

Too much reliance should not be placed upon the character of the 
cough, as it is very apt to vary with the duration of the cough, medi- 
cation and complications. By far more reliable information can be 
obtained from a careful examination of the expectoration. 

Sputum, Expectoration 

In cases where the children cannot or will not expectorate, the 
sputum may be obtained by introducing into the throat a sterile 
cotton swab or fenestrated stomach tube — both of which usually re- 



EXAMINATION OF THE PATIENT 139 

ceive enough of sputum during the act of coughing to suffice for or- 
dinary examination. 

The expectoration is — 

1. Mucous, frothy, grayish-white, in acute catarrh of the air pas- 
sages. 

2. Mucopurulent, tenacious, yellowish-gray, in chronic tracheo- 
bronchial catarrh; in pertussis (voluminous, often mixed with vomi- 
tus) ; in asthma (Curschmann's spirals, Charcot's crystals) ; in bron- 
chiectasis (periodic "mouthful expectoration," separable into a puru- 
lent and mucoserous layer). 

3. Purulent, fetid, dirty grayish-green, in fetid or putrid bronchi- 
tis (separable into three layers; suspended in the lowest, purulent 
layer are Dittrich's plugs); in pulmonary abscess (separable into two 
distinct layers, containing a great number of micrococci, elastic fibers, 
fat crystals, etc.) ; in pulmonary gangrene (same as putrid bronchitis, 
plus tissue fragments). 

4. Serous, prune-juice-like, and profuse, in pulmonary edema. 

5. Bloody, in nasopharyngeal catarrh with violent paroxysms of 
coughing (occasional streaks of blood) ; in foreign bodies in the air 
passages (bright red mixed with frothy mucus) ; in pneumonia (uni- 
formly stained, "rusty" sputum to dark "prune juice" color with 
pneumococci) ; in influenza (often bright red and profuse); in heart 
disease with edema (the same as in pulmonary edema from other 
causes; besides "heart-cells"); in tuberculous lesions of the air pas- 
sages (either large hemorrhage, "hemoptysis," or blood stained "num- 
mular" and heavy sputum, containing tubercle bacilli); in neoplasms 
("red currant "-like sputum, with characteristic histologic structures); 
in vicarious menstruation; hemorrhagic diathesis, and hysteria. (See 
"Hematemesis" and "Epistaxis. ") 

The expectoration contains numerous microorganisms and occa- 
sionally bile (icterus), hydatid hooklets, distomum pulmonale, and 
cercomonas. 

The Heart* 

The heart is comparatively larger in infancy than in later life. It 
is relatively largest at birth, and smallest at about the age of seven 
years. At birth the Avails of both ventricles are nearly of equal 
thickness, but as the infant grows older, the left ventricle rapidly 
gains in thickness, so that by the end of the second year it is almost 
twice as thick as the right ventricle. 



See "Auscultation" and "Percussion," p. 129. 



no 



DISEASES OF CHILDREN 



Corresponding to the relatively larger size and more transverse 
position of the heart of the young child, its boundaries are greatly 
at variance from those of the heart of the adult. 
The boundaries of the normal heart — 
The apex heat is situated— 

To the left of the mammary line, in the fourth intercostal 

space, up to the fourth year of age. 
At the mammary line, slightly below the fifth rib, up to the 
eighth year. 




Fig. 16. — Normal heart of a child three years old. 



Slightly to the right of the mammary line, in the fifth inter- 
costal space, up to the twelfth year. 

Between the mammary and parasternal lines, i. e., the same 
as in the adult, in children over twelve years. 
The Relative "heart dulness" in infants is bounded as follows: 

Above, by a line corresponding to the lower border of the 
second rib. 



EXAMINATION OF THE PATIENT 141 

On the left side, by a line parallel and slightly to the left 

of the left mammary line. 
On the right side, by the right parasternal line. 
Below, by a somewhat semicircular line along the fifth rib. 
As the child grows older and the heart assumes a more oblique and 
lower position, the boundaries of the relative heart dulness gradually 
fall in line with those of the adult. 

The absolute "heart dulness" in infants is bounded as follows: 
Above, by the upper border of the fourth rib. 
On the left side, by the left mammary line (slightly to the 
right of it). 




Fig. 17. — Normal heart of a child eight years old. 

On the right side, by the left sternal line. 

Below, by a line corresponding to the upper border of the 
fifth rib. 
These boundaries, like those of the relative heart dulness, change 
gradually with the advance of the child's age, so that in children over 
twelve years old, the upper boundary is formed by the fourth rib ; the 
lower by a line drawn parallel to and between the fifth and sixth ribs ; 
on the right side, by the sternal line ; and on the left by a line midway 
between the parasternal and mammary lines. (See Figs. 18, 19, and 20.) 



112 



DISEASES OF CHILDREN 



The normal pulse rate (most reliable when patient is asleep)- 
In the newborn from 120 to 150 per minute. 
At one year old, 100 to 120 per minute. 
At four years, 90 to 100 per minute. 
At eight years, 80 to 90 per minute. 
At twelve years, 75 to 80 per minute. 



PARASTERNAL 
LINE 



PARASTERNAL 
LINE 



MAMMARY 
- LINE 




Fig. 18. — Up to four years. 



MAMMARY 




PARASTERNAL 
LINE 



PARASTERNAL 
LINE 




Fig. 19. — Up to eight years. Fig. 20. — Up to twelve years. 

The relative and absolute heart duluess at different ages. 



Normal pulse respiration ratio is approximately 1:4. A ratio of 1:3 or 
less is a certain indication of pulmonary disease, especially pneu- 
monia. 
Apex beat — 

1. Displaced — 

Outward, to the left, in hypertrophy of the right ventricle; 
dilatation of the right ventricle; right-sided pleurisy with 
effusion; right-sided pneumothorax; abdominal distention 
pushing the diaphragm upwards and the heart to the left. 
Outward and downward, in hypertrophy of the left ventri- 
cle ; dilatation of the left ventricle ; pericardial effusion ; 
congenital or acquired (by pressure from above, e. g., tu- 
mor or abscess) dislocation of the heart. 



EXAMINATION OF THE PATIENT 143 

Inward, to the right, in left-sided pleuritic effusion; pro- 
nounced left-sided deformity of the thorax; persistence 
of the embryonic position or situs inversus (up to dextro- 
cardia). 

2. Effaced (i. e., apex beat is invisible and barely palpable), in obes- 

ity; pericardial effusion; heart failure; emphysema; edema 
cutis ; tumors. 

3. Diffuse and weak in irregularity of the heart associated with 

grave heart disease. 

4. Diffuse and strong, in cardiac hypertrophy; hyperpyrexia; over- 

stimulation ; excitement. The cardiac impulse may only appear 
strong when the chest wall is very thin. 
Heart sounds — 

Accentuation of — 

1. Systolic mitral, in excitement; fatigue; fever; l^pertrophy 

of the left ventricle. 

2. Diastolic pulmonic, in hypertrophy of right ventricle. 

3. Diastolic aortic, in hypertrophy of left ventricle. 
Weakening of — 

1. Systolic mitral, in dilatation of the left ventricle; loss of 

compensation. 

2. Diastolic pulmonic, in dilatation of the right ventricle (e. g., 

relative tricuspid insufficiency) ; stenosis of pulmonary ar- 
tery. 

3. Diastolic aortic, in aortic stenosis. 

Division (double) of diastolic at apex, in mitral stenosis; adhesive 
pericarditis. 

Gallop rhythm, in heart failure from various causes (e. g., incipient 
diphtheritic paralysis) ; noncompensating heart disease ; tachy- 
cardia. 

Metallic ringing, in pneumopericardium; pneumothorax; large pul- 
monary cavity; intense meteorism. 
Heart murmurs — 

1. Systolic, loudest at apex and transmitted to axilla and angle 

of left scapula, in mitral regurgitation. 

2. Systolic, loudest at base (midsternum) and transmitted to 

the arteries upward and sometimes over the whole ster- 
num, in aortic obstruction. 

3. Systolic, at base, but not transmitted upward, in pulmonic 

obstruction. 

4. Systolic, loudest at ensiform cartilage, in tricuspid regur- 

gitation. 



144 



DISEASES OF CHILDREN 



5. Diastolic, loudest at base, and transmitted to apex and ensi- 

form cartilage, in aortic regurgitation. 

6. Diastolic, or presystolic, loudest at apex, in mitral obstruc- 

tion. 

7. To-and-fro-friction, superficial, limited to precordium; not 

influenced by respiration (as is the case in pleuritis sicca), 
in fibrinous pericarditis. 




Fig. 21. — Topography of cardiac valves. Points of transmission of heart murmurs. 

A. 0. Aortic obstruction. P. 0. and B. Pulmonic obstruction and regurgitation. A. 

B. Aortic regurgitation. T. 0. and B. Tricuspid obstruction and regurgitation. M. 
0. Mitral obstruction. M. B. Mitral regurgitation. 



Areas of heart dulness — 

Enlarged — 

1. To the left, in hypertrophy or dilatation of the left ventricle. 

2. To the right, in hypertrophy or dilatation of the right 

ventricle. 

3. Bilaterally, in pericardial effusion. The area of dulness 

is larger in sitting than in recumbent posture ; it is often 
triangular ; wider below than above. 



EXAMINATION OF THE PATIENT 145 

Reduced — 

In pulmonary emphysema; pneumopericardium. 

Displaced — 

1. In congenital malpositions, e. g., dextrocardia, mesocardia, 

diaphragmatic hernia. 

2. In acquired affections, such as pneumothorax; pleurisy with 

effusion; neoplasms; pleuritic retraction; atrophy of the 
lungs. 

The pulse — 

1. Frequent, in fright; excitement; fear; febrile diseases (except 

uncomplicated typhoid or meningitis) ; valvular heart diseases 
(except aortic stenosis) ; anemias, especially on slight exertion; 
tachycardia; exophthalmic goiter; convalescence from acute 
affections; paralysis of the heart (central or peripheral paral- 
ysis of pneumogastric nerve); heart failure (e.g., collapse in 
febrile diseases). 

2. Slow, in uncomplicated typhoid fever or meningitis ; after crises 

(e.g., pneumonia) ; acute nephritis; catarrhal jaundice; intra- 
cranial pressure (e.g., hydrocephalus, hemorrhage, tumors); 

heart disease, such as aortic stenosis, myocarditis ; bradycardia ; 
profuse hemorrhage; marked inanition (e.g., a pyloric steno- 
sis) ; opium poisoning. 

3. Irregular, in last stages of valvular heart disease; myocarditis; 

profound anemia (on exertion); nervous palpitation; indiges- 
tion (flatulent colic). 
In the irregular pulse we distinguish the — 

1. Intermittent pidse — 

Pulsus alternans (every second beat weak). 
Pulsus bigeminus (every third beat weak). 
Pulsus trigeminus (every fourth beat weak). 

2. Inter cidens pulse (several regular beats suddenly followed by a 

small beat and pause), in heart weakness. 

3. Paradoxic pulse (the pulse grows smaller or ceases entirely on 

deep inspiration), in adhesive pericarditis; constriction of the 
air passage; mediastinal tumors; during "whoop" in pertussis. 

4. Dicrotic or double pulse (in part explained by a loss in the mus- 

cular tone in the arteries, so that the arterial impulse is sepa- 
rated from that of the ventricles by a perceptible interval), in 
typhoid fever and less marked in other acute febrile diseases ; in 
chronic wasting diseases, especially tuberculosis ; in anemias ; af- 
ter great loss of blood. 



146 



DISEASES OF CHILDREN 



5. Asymmetric (radial) pulse, in congenital anatomic variations of 
the artery on one side; acquired narrowing, compression; or 
cicatricial contraction of the radial, brachial, axillary, sub- 
clavian or innominate artery; aneurysm of the aforementioned 
arteries or of the aorta ; in pneumothorax compressing the sub- 
clavian artery. 

THE ABDOMEN AND ITS CONTENTS 

In order to save time, inspection and palpation of the abdomen may 
at once be supplemented by percussion, succussion, etc. To judge 




Fig. 22. — The thoracic and abdominal region; 

3. Inguinal. 



1. Hypochondriac. 2. Lumbar, 



matters correctly we should bear in mind the normal relations of the 
abdominal parietes to the underlying structures. 

The abdominal wall is moderately arched ; readily compressible with- 
out undue resistance or pain; moves slightly upward and downward 
quite evenly and regularly with inspiration and expiration; and on 



EXAMINATION OF THE PATIENT 147 

percussion yields a loud, tympanitic sound over all portions of the 
abdomen engaged by the intestines. 

The stomach at birth is nearly cylindrical and lies obliquely in the 
abdominal cavity. Thus, the cardiac end on a level with the tenth dorsal 
vertebra, and the pyloric end in the median line and slightly to the 
right, midway between the tip of the xiphoid cartilage and the 
umbilicus. The pylorus is not palpable. Gradually the fundus increases 
in size (at seven months it is twice the original length) and the stomach 
assumes a transverse position in such a manner that five-sixths of its 
volume occupies the left half of the abdomen and one-sixth the right. 
The capacity of the stomach varies, of course, with the age and size 
of the child, as fully given when discussing "infant feeding" p. 55. 
The stomach empties itself in breast fed babies in two hours; in arti- 
ficially fed in three hours. The stomach is dilated in congenital py- 
loric stenosis (shown by the bismuth radiogram test, see Fig. 58) ; also in 
general atony. 

The infantile intestines, especially the small intestine, are relatively 
longer than those of the adult. At birth the small intestine is about 
9 feet long, the large intestine about 18 inches, the sigmoid flexure 
forming about half of the colon. The capacity of the infantile intes- 
tines is relatively greater than in the adult, but their musculature is 
thinner and weaker, hence the tendency to constipation and colic. 
The intestines are — 

1. Dilated, in megacolon congenitum; above constriction in stenosis 

or atresia; intussusception; chronic constipation; prolonged me- 
teorism. 

2. Contracted, below the seat of constriction; compression by ab- 

dominal tumors. 

The liver of the newborn is relatively very large in size, much larger 
than in the adult, constituting in the former about one-eighteenth, and 
in the latter about one-thirty-sixth of the entire body weight. 

As the child grows older the size of the liver is greatly reduced, but 
owing to the sloping course of the lower ribs the liver appears con- 
siderably larger than it actually is. 
Normal boundaries of the liver (as determined by percussion) — 

1. Upper border, at midsternal line, base of ensiform cartilage ; mam- 

mary line, sixth rib; midaxillary line, eight rib; scapular line, 
tenth rib. 

2. Lower border, parasternal line, seventh rib ; mammary line, about 

y 2 inch below free border of the ribs; midaxillary line, tenth 
rib ; scapular line, eleventh rib. 

3. Left border, joins lower absolute heart dulness. 



148 



DISEASES OF CHILDREN 



4. Eight border, joins the right kidney. 

Its position varies greatly with the ascent and descent of the dia- 
phragm — rises with expiration and descends with deep inspiration. In 
the same manner it rises with intestinal meteorism and descends with 
overdistention of the lungs through disease, e. g., emphysema or pneu- 
mothorax. 




Fig. 23. — Dissection of still-born child. Note the relatively large size of the liver; 
note also peculiar course of sigmoid. (Henry Enos Tuley.) 



The liver is — 

1. Enlarged, in congenital syphilis; tumors; or cysts; liver abscess; 

chronic heart disease; acute septic processes; abdominal tuber- 
culosis; splenomegaly (Gaucher) ; amyloid degeneration; hyper- 
trophic cirrhosis; Banti's disease. 

2. Displaced, in congenital dislocation; rachitis; right extensive 

pleural effusions. 



EXAMINATION OF THE PATIENT 149 

The spleen lies in close contact with the diaphragm, and extends 
from the left midaxillary line to a point near the left border of the 
spinal column. Its upper border follows the ninth rib. its lower bor- 
der the eleventh rib, for the most part bounding the left kidney. 
Normally the spleen cannot be outlined by percussion, but during 
deep inspiration it can sometimes be palpated at the free borders of 
the tenth and eleventh ribs. 




Fig. 24. — Topography of the liver and spleen. 

The spleen is — 

1. Enlarged, primarily, in leukemia, pseudoleukemia; in von 

Jaksch's anemia; splenitis; splenomegaly (Gaucher); Band's 
disease; tumors; secondarily, in malaria; all septic processes; 
tuberculosis; typhoid; rachitis; syphilis; liver disease. 

2. Displaced, in pleural effusions; deformities of chest; after severe 

coughing (pertussis). 
The kidneys are situated upon the right and left sides of the spinal 
column, and extend from the levels of the twelfth dorsal to the 
second lumbar vertebras. The uppermost end of the right kidney 



150 



DISEASES OF CHILDREN 



(the suprarenal capsule) is slightly overlapped by the liver; that of 
the left kidney by the spleen. Normal kidneys are usually palpable 
when the abdomen is relaxed, but can never be outlined by percussion. 
The urinary bladder is situated underneath the symphysis pubis, but 
when fully distended rises above it, eliciting dull percussion resonance. 
Abnormal size and shape of the abdomen — 

1. Large and uniform, in flatulence ; in acute and chronic gastro- 
enteritis; acute peritonitis from various causes; late stage of 
grave pneumonia ; intestinal atony or paralysis ; extensive ascites. 




Fig. 25. — Topography of kidneys, spleen, and liver. S. Spleen. L. Liver. K. Kidneys. 



2. Ketracted, in collapse, especially from gastrointestinal disease; in 
inanition (pyloric or esophageal stenosis) ; meningitis ("sca- 
phoid abdomen"); general cachexia and loss of fat and muscle. 
Increased abdominal resistance — 

1. Local, in localized affections of the different abdominal organs 
(tumors, abscesses, foreign bodies, e.g., fecal impaction; hel- 
minthiasis). 



EXAMINATION OF THE PATIENT 151 

2. General, in hyperesthesia; rheumatism of abdominal muscles; 
colic; peritonitis from different causes; appendicitis; sclerema; 
scleredema; extensive dropsical effusion. 
Abdominal pain — 

In all conditions enumerated under "abdominal resistance," except 
sclerema; scleredema, and dropsy. In pneumonia, pleurisy 
(reflex) ; in cholelithiasis; gastralgia; ulcer; nephrolithiasis; cysti- 
tis ; vesical calculi ; intestinal adhesions ; ren mobilis ; uterine and 
ovarian diseases (in older girls) ; in hysteria. 

Visible intestinal peristalsis — 

1. Normal, in very thin and lax abdominal parietes, e. g., congenital 

diastasis recti abdominis (Fig. 37) ; infantile athrepsia ; atrophy 
due to paralysis. 

2. Abnormal (increased or reversed), in pylorus stenosis; intestinal 

obstruction or constriction from various causes; congenital dila- 
tation of the colon. 
Palpable or visible herniae — 

1. In the linea alba (ventral; diastasis recti abdominis). 

2. At the umbilicus (congenital hernia of the cord, ectopia viscerum; 

simple umbilical hernia). 

3. In the lumbar triangles (lumbar hernia; lateral ventral hernia). 

4. In the inguinal regions (direct and oblique inguinal hernia). 

5. At the femoral fossa (femoral or crural hernia). 

The Diagnostic Significance of Chronic Abdominal Enlargement 

Chronic abdominal enlargement in children is of common occurrence 
and in the majority of instances is due to rachitis and protracted in- 
testinal indigestion. Occasionally, however, it is the result of certain 
grave intraabdominal pathologic conditions. 

The liver, occupying as it does a wide area of the upper abdominal cav- 
ity (see Fig. 23), is very prone to cause considerable abdominal enlarge- 
ment even when slightly exceeding its normal boundaries, as in slight 
downward displacement or enlargement. Displacement of the liver, 
which, by the way is often mistaken for enlargement, is usually the 
result of rachitic deformity of the chest, but may occasionally be 
met with in consequence of large pleuritic effusions, emphysema, 
and pneumothorax. In rachitic displacement the diagnosis can 
readily be made by percussion, when it is found that the liver dul- 
ness, instead of beginning on a level with the sixth rib, starts any- 
where below this upper normal boundary. The same holds true 
with displacement accompanying emphysema or pneumothorax, 



152 DISEASES OF CHILDREN 

but here we have in addition the clinical signs of these affections to 
go by, especially barrel-shaped chest and exaggerated resonance on 
percussion in the former, and the acute onset and tympanitic percus- 
sion sounds in the latter. The diagnosis of hepatic displacement sec- 
ondary to pleurisy with effusion is often difficult, owing to the diffi- 
culty of distinguishing the dulness of the liver from that of the pleu- 
ritic effusion, but the diagnosis can ordinarily be cleared up by ex- 
ploratory puncture. Enlargement of the liver sufficient to produce 
marked abdominal enlargement is usually observed in connection 
with syphilis, neoplasm, abscess, hepatic cyst, and congenital ob- 
literation of the bile duct, or secondary to pronounced heart or 
spleen affections. In older children we must think also of peri- 
cardiac pseudocirrhosis of the liver (Pick's disease), which is asso- 
ciated with rheumatic or tuberculous obliteration of the pericardium 
and is manifested by enlargement of the spleen and liver and by as- 
cites. In older children also we occasionally meet with abdominal en- 
largement due to ascites associated with hypertrophic and atrophic 
cirrhosis of the liver owing to abuse of alcoholic beverages. 

Occasionally a phantom tumor (localized meteorism and contraction 
of the intestinal muscles; usually of a hysterical nature) in the epi- 
gastrium, may be mistaken for a large liver. The tumor gives a tym- 
panitic note; there is no fluctuation; it disappears under anesthesia. 

In examining the spleen we should bear in mind that any spleen 
that is palpable is either diseased or displaced. The displacement 
may be either congenital, the so-called "wandering spleen,"^ or ac- 
quired as a result of prolonged and severe coughing, e.g., in pertus- 
sis. A displaced spleen is rarely the cause of marked abdominal en- 
largement, and the same is true of a slightly enlarged spleen, unless 
it be associated with rachitis. The spleens, large enough independ- 
ently greatly to influence the abdominal contour of children, are or- 
dinarily encountered with anemia pseudoleukemica infantum, leuke- 
mia, syphilis, neoplasms or primary splenohepatomegaly (Gaucher) (see 
Fig. 158), more especially with the latter affection. Finally, on very rare 
occasions abdominal enlargement is found to be due to so-called Banti's 
disease, which is characterized by splenomegaly, anemia, cirrhosis of 
the liver, ascites, and hemorrhages. 

The usual kidney affections are not productive of abdominal en- 
largement except in their late stages as a result of dropsical effu- 
sions within the abdominal cavity, or of secondary involvement of other 
organs. In such cases the diagnosis is obvious. As we palpate the 
kidneys, which procedure is readily accomplished especially when 
they are displaced or enlarged, we should be watchful for hydroneph- 



EXAMINATION OF THE PATIENT 



153 



rosis and neoplasms. Hydronephrosis, in order materially to change 
the outline of the child's abdomen, is usually large enough readily to 
be felt as an immovable, fluctuating mass in the lumbar region, but 
considerable difficulty is experienced in differentiating unilateral hy- 
dronephrosis from a cystic tumor of the kidney. As hydronephrosis is 
due either to congenital atresia or acquired occlusion of the ureter, its 
differentiation from cystic kidney can be made only by a careful ure- 
ter oscopic examination or puncture of the mass (showing the pres- 




Fig. 26. — Sarcoma of the left kidney. 



ence of urine) through the abdominal wall. Ordinarily one would 
rarely err in diagnosing a kidney neoplasm rather than hydronephro- 
sis, since the former is by far more common than the latter. This 
is true, especially of sarcoma. Hard tumors of the kidney are best 
diagnosed by palpation, if need be under anesthesia, although some 
diagnostic help is also obtained from the x-rays. No great reliance 
should be placed upon hematuria as a characteristic sign of renal 



154 



DISEASES OF CHILDREN 



neoplasm, since blood in the urine is frequently found in renal 
tuberculosis, hemorrhagic nephritis, purpura, and other diseased con- 
ditions, and is often absent in kidney tumors when large enough to 
obstruct the ureter so that no urine is excreted from the affected side. 
Next to rachitis, tuberculosis of the peritoneum or intestines forms 
the most frequent cause of abdominal enlargement in children. But 
while we meet these cases almost daily in hospital, dispensary, and 
private practice, the diagnosis is not always easy. It is often espe- 
cially difficult to detect tuberculosis of the intestines. The tubercu- 
lous lesions are usually located in the lower portions of the ileum, 




Fisr. 2; 



-High degree of rachitis. Abdominal enlargement chiefly in epigastric region. 



ileocecal region, and colon, but owing to the accompanying intense 
meteorism, the intestinal tumefaction is beyond reach of palpation, par- 
ticularly during the early stages. However, as the diagnosis can fre- 
quently be established by the demonstration of tubercle bacilli in the 
stools, these should always be subjected to minute bacteriologic ex- 
amination whenever stubborn diarrhea and rapid emaciation prevail. 
Less difficulty, as a rule, is experienced in the diagnosis of tuberculous 
peritonitis, because the tuberculous peritoneal masses are more super- 
ficial and hence more readily palpable, and also because of the pres- 



EXAMINATION OF THE PATIENT 



155 



euee of fluid in the abdominal cavity. A positive tuberculin reaction, 
of course, is corroborative of the diagnosis. It should be borne in mind, 
however, that a negative result by no means proves the absence of tu- 
berculosis. This point is deserving of special emphasis. I desire to 
call particular attention to a physical sign which proved to me very 
helpful in differentiating abdominal enlargement associated with rachi- 
tis from that of tuberculous peritonitis. Whereas in rachitis (Fig. 
27) the greatest prominence of the abdomen is manifested at the 
epigastrium, in tuberculous peritonitis (Fig. 28) the abdominal cir- 
cumference is largest at or below the umbilicus (hypogastrium). This 
differential physical sign can best be elicited by careful measurements 




Fig. 28. — Tuberculous peritonitis. Abdominal enlargement most marked in hypogas- 
tric region. 

of the abdominal circumference by means of a tape measure, but can 
readily be determined also by mere inspection. This sign can be ex- 
plained by the fact that in tuberculous peritonitis the inflammatory 
exudate accumulates at the bottom of the abdominal cavity and thus 
distends the surrounding abdominal wall. To make correct use, how- 
ever, of this sign we must be sure to exclude large dermoid cysts 
of the ovary and an overdistended bladder, both of which conditions 
are apt to lead to diagnostic errors. 

There is one other intestinal abnormality which often gives rise to 
an enormous abdominal enlargement in children, and that is, congenital 
or acquired hypertrophy and dilatation of the colon, the so-called Hirsch- 



156 DISEASES OF CHILDREN 

sprung 's disease (see Fig-. 34). While it was originally thought to be 
a congenital affection only, it has lately been shown to develop grad- 
ually also after birth. In these cases particularly the diagnosis is 
often very difficult, but nowadays, with, the help of the x-ray, the diag- 
nosis can readily be made, even if the usual symptoms of the disease 
fail to disclose the pathologic condition. 

Vomiting — 

1. Gastroenteric (associated with nausea and effort; followed by re- 

lief), in simple gastroenteric disturbances and intoxication; 
pyloric stenosis or spasm; acidosis; intestinal obstructon from 
various causes ; appendicitis ; peritonitis ; the effect of emetics 
or poisonous drugs (taken by mouth). 

2. Cerebral (explosive; watery, recurrent without relief). 

(a) Direct, in acute and chronic affections of the cerebrospinal 
system ; shock ; psychic emotion. 

(&) Keflex, in extracranial irritation of the cranial nerves, e.g., 
of the optic or oculomotor nerves in visual defects ; of the 
auditory nerve, in otitides; pneumogastric, in pulmonary and 
cardiac diseases. Also in toxemia, by bacterial or chemical 
products {e. g., sepsis, uremia, etc.). To the latter group be- 
longs the vomiting accompanying migraine. 

Vomitus — 

1. Mucous, in chronic catarrh of the stomach; after swallowing large 

quantities of expectoration, in nasopharyngeal and laryngeal 
inflammation or pertussis. 

2. Bilious (yellowish-green or green), in gastroenteric disturbances af- 

ter repeated vomiting ; in peritonitis ; intestinal obstruction ; liver 
affections; in the late stages of acidosis. 

3. Bloody (hematemesis), in hemophilia and melena neonatorum; con- 

genital obliteration of the bile ducts; cirrhosis of the liver; ul- 
ceration of the lining of alimentary tract, especially of the 
upper part (from corrosive poisons; syphilis, etc.) ; in vicarious 
menstruation. 

4. Purulent, in rupture into the stomach of large abscesses in the 

adjacent organs {e.g., empyema). 

5. Fecal, in severe intestinal obstruction with reversed peristalsis 

{e.g., intussusception). 

6. Parasitic, in helminthiasis; anchylostomiasis ; trichiniasis ; echino- 

coccosis. 



EXAMINATION OF THE PATIENT 157 

Diarrhea. 1 " — One to two movements in twenty-four hours are looked 
upon as normal. But even double the number of evacuations is 
not necessarily a manifestation of a pathologic condition unless 
the consistency, color and odor of the stools are materially al- 
tered. Since on the first visit a specimen of the stool is not al- 
ways obtainable, and even if obtained is not invariably of the 
same consistence as the preceding movements, it is important to 
gather all the information possible as to the abnormality in ques- 
tion — number., time of occurrence, quantity and quality. 

1. Acute diarrhea occurs after the administration of cathartics 

or corrosives: in indigestion: stomatitis: gastroenterocolitis ; 
proctitis and dysentery (blood, mucus and often pus) ; acute 
peritonitis ; during the course of divers infectious diseases, 
especially cholera, typhoid, scarlatina, measles, influenza, sep- 
sis, etc. 

2. Chronic diarrhea is observed in dyspepsia; chronic gastroen- 

terocolitis: chronic proctitis and dysentery (amebic); intes- 
tinal tuberculosis and other chronic wasting diseases (es- 
pecially syphilis, leukemia, amyloidosis) ; helminthiasis (espe- 
cially in trichocephalus and ankylostomum — often mucosan- 
guinolent stools ; malaria (periodic) ; intestinal lithiasis (mu- 
cus, blood and sand . and in partial intestinal stenosis band- 
like, flat, mixed with mucus). * 
Constipation.^ — In determining the clinical significance of consti- 
pation, inquiry should be made as regards the duration of the 
constipation, mode of feeding the child, presence or absence of 
vomiting and tenesmus, and the color and consistency of the stools. 

1. Habitual constipation occurs in consequence of insufficient (py- 

loric stenosis; or improper feeding (excess of fat or starches. 
etc.) ; intestinal atony ('from a great number of causes, e. g.. 
congenital or acquired muscular insufficiency — megacolon, or 
artificial distention), general debility, cretinism, etc.; partial 
intestinal obstruction {e.g., hernia, neoplasms and abstinence 
owing to painful lesions in the rectum [e.g., hemorrhoids, fis- 
sures). 

2. Acute constipation, with persistent vomiting, pain, meteorism, 

etc., in all forms of congenital intestinal atresia and acquired 
acute intestinal obstruction intussusception, strangulation. 
fecal impaction, peritonitis, appendicitis, and volvulus). 



See '"Infants' Stools." p. 158; also "Infant Feeding," p. 55. 



158 DISEASES OF CHILDREN 

INFANTS' STOOLS 

The character (consistency, color, reaction, odor, etc.) of infants' 
stools greatly depends upon the kind and quantity of food consumed. 

Normal stools — 

1. Soft and pasty, golden yellow, slightly acid and almost odorless, 

in breast-milk feeding. 

2. Soft, putty-like, whitish-yellow, slightly alkaline and slightly 

offensive in odor, in cow's milk feeding. 

3. Soft, salve-like, yellowish-brown or brown, slightly alkaline 

or neutral, and malt-like in odor, in feeding with malted or 
farinaceous foods. 

Abnormal stools — 

(a) Consistency — 

1. Soft, smeary, like moistened shavings of soap, or grayish 

yellow, hard and dry ' ' soap stools, ' ' in fat indigestion. 

2. Soft or hard and mixed with tough white curds, in casein 

indigestion; hard, lumpy, in habitual constipation. 

3. Loose, brown stools mixed with mucus in starch indigestion. 

4. Thin, yellowish green in gastroenteritis; typhoid fever; 

from the effects of hydragogue cathartics; rectal stricture 
{e.g., syphilitic). 

5. Serous, in severe gastroenterocolitis ; cholera. 

6. Mucous, in obstinate constipation with tenesmus; in disease 

of the large intestine (colitis, large quantity) ; in disease 
of the small intestine (mixed with feces). 

7. Bloody, in rectal affections {e.g., proctitis, hemorrhoids, 

foreign bodies, fissure, polypus, prolapsus); dysentery; 
intussusception; hemorrhagic diseases {e.g., melena, pur- 
pura, hemophilia). 
(6) Color— 

1. Yellowish-green, in gastrointestinal indigestion (especially 

of casein). 

2. Green, in gastroenteritis; excess of sugar; from the effects 

of calomel. 

3. Clay-color, in obstruction to the flow of bile. 

4. Black, in meconium; from the effects of iron, manganese 

and bismuth; also from blood (coming from upper portion 
of the bowels). 

5. Eed, from admixture of blood (from lower portion of bowels, 

especially rectum). 



EXAMINATION OF THE PATIENT 159 

(c) Reaction— 

1. Decidedly alkaline, in protein indigestion. 

2. Moderately acid, in fat indigestion (from fatty acids) ; car- 

bohydrate indigestion (acetic or lactic acid). 

3. Strongly acid, in sugar indigestion. 
{d) Odor— 

1. Foul, in protein indigestion. 

2. Eancid, in fat indigestion. 

3. Sour or pungent, in carbohydrate indigestion. 

The stools should be examined also for parasites (see "Intestinal 
Worms," p. 276) and calculi. 

(e) Bacterial flora — 

1. In breast-fed feces: B. bifidus communis; B. acidophilus; 

few coli ; and B. lactis aerogenes. 

2. In cow's milk fed feces: B. coli communis (splits milk sugar 

in lactic acid, carbonic acid and water, and partly splits 
fat in fatty acids) and with it in varying number B. acid- 
ophilus, micrococcus ovalis; enterococcus (Thiarceli), 
Gram-staining diplococcus, strepto- and staphylococci, sar- 
cinas and B. lactus aerogenes (splits milk sugar into lactic 
acid, carbonic acid and water, causing the intestinal con- 
tents to become acid). 

Principal Abnormalities of Urine 

In male infants the urine may be collected by placing the penis in 
a test tube or the neck of a bottle, fastened by means of strips of 
adhesive plaster; in female infants, by placing absorbent cotton in 
front of the vulva, or placing the buttocks on a flat bed pan. AVhere 
these measures fail, catheterization should be resorted to. 

Traces of albumin and sugar ; occasionally hyaline and granular 
casts; a moderate amount of mucus, uric acid crystals, and urea, are 
found in the urine of healthy infants in the first few weeks of life. 

The quantity of urine passed in twenty-four hours is larger in infants 
than in older children, but varies with the amount of liquid con- 
sumed. It is smaller in breast-fed than in bottle-fed babies. 

Polyuria in — 

1. Diabetes mellitus. 

2. Diabetes insipidus. 

3. Contracted kidney. 

4. Granular atrophy of the kidney. 

5. Amyloid kidney. 



160 DISEASES OF CHILDREN 

6. Convalescence after acute diseases (epicritic polyuria). 

7. Disease of the nervous system, functional and organic, as hys- 

teria, neurasthenia, migraine, chorea, epilepsy, tabes, cerebro- 
spinal meningitis. 

8. Medicinal (acetates, salicylates, digitalis, calomel, etc.). 

Oliguria in — 

1. Febrile conditions. 

2. Profuse diarrhea. 

3. Circulatory disturbances. 

4. Acute nephritis. 

5. Some forms of chronic nephritis. 

Anuria in — 

1. Atresia urethral, in the newborn. 

2. Uremia. 

3. Acute anemia (after severe hemorrhage). 

4. Catarrh of the stomach or intestines. 

5. Cholera. 

6. Dysentery. 

7. Nervous manifestations. 

8. Lead colic. 

9. Poisoning with arsenic, corrosive sublimate, morphine, atro- 

pine, oxalic acid, etc. 

Glycosuria — 

(a) Constant, in diabetes mellitus. 

(b) Transient in — 

1. Cholera. 

2. Typhoid fever. 

3. Intermittent fever, particularly during convalescence. 

4. Syphilis. 

5. Scarlatina. 

6. Measles. 

7. Diphtheria. 

8. Influenza. 

9. Gout. 

10. Disease of the lungs and liver. 

11. Disease of the brain, involving the fourth ventricle. 

12. Cerebrospinal meningitis. 

13. Tetanus. 

14. Lesions affecting the central and peripheral nervous system. 



EXAMINATION OF THE PATIENT 161 

15. Poisoning with morphine, atropine, strychnine, oxalic acid, 
carbon monoxide, lead, chromates, chloroform, ether, etc. 
(c) Transient, alimentary in — 

1. Disorder of the stomach. 

2. Overingestion of starchy and saccharine foods. 

3. Cirrhosis of the liver. 

4. Morbus Basedowii. 

5. Disease of the heart. 

6. Phosphorus poisoning. 

7. Atrophy of the liver. 

8. Traumatic neuroses. 

»9. Fatty degeneration of the liver. 
10. Psoriasis. 

Acetone in — 

1. Diabetes mellitus, especially in advanced cases; diabetic coma. 

2. Acidosis. 

3. Fever; inanition. 

4. Carcinoma. 

5. Autointoxication. 

6. Psychoses. 

7. After chloroform narcosis. 

Diacetic acid in — 

1. Diabetes mellitus, advanced cases. 

2. Autointoxication (diacetonuria) acidosis. 

Albuminuria — 

(a) Renal (nephritis, pyelitis, pyelonephritis, nephrolithiasis). 
(6) Vesical (calculi, colicystitis) ; in tumors. 
(c) Changes in the constitution of the olooel — 

1. Ischemia. 

2. Anemia. 

3. Struma. 

4. General weakness. 

5. Effect of certain poisons, as cantharides, mustard, oil of tur- 

pentine, carbolic acid, alcohol, lead, etc. 

6. Infectious fevers — Microorganisms in the blood. 

7. Febrile conditions. 

(el) Disturbance in the circulation — 

1. Acceleration of the arterial current. 

2. Slowing of the venous current. 

3. Prolonged muscular exercise. 



162 DISEASES OF CHILDREN 

4. After cold baths. 

5. After epileptic fits. 

6. Compression of the thorax. 

7. Derangement of the cerebrospinal system. 
(e) Functional — 

Orthotic, lordotic. 
(/) Digestive — 

Ingestion of excessive quantities of albumin (e. g. f eggs, cheese, 
raw beef). 
Casts — 

(a) Hyaline (narrow and broad), in 

Acnte and chronic nephritis. 
(6) Granular (coarse and fine grannies), in 

Chronic pathologic conditions of the kidney. 

(c) Epithelial, in 

Inflammation in the anatomical structure. 

(d) Bloody, in 

1. Hematuria. 

2. Acute diffuse nephritis. 

3. Acute renal congestion. 

4. Hemorrhagic infarction of the kidney. 

(e) Fatty, in 

Fatty changes in the kidney, large white kidney. 
(/) Waxy, in 

Amyloid kidney and many forms of nephritis. 
(g) Bacterial, in 

Interstitial suppurative nephritis, ascending pyelonephritis. 
(h) Purulent, in 

Abscess of the kidney. 

Uric acid (pathologic, when deposit occurs shortly after urine is 
voided) in — 

1. Acute fevers. 

2. Increased tissue metabolism. 

3. Defective physiologic action of the liver. 

4. Sedentary habits of life. 

5. Early stages of interstitial nephritis. 

6. Convalescence from scarlatina, etc. 

Hematuria (blood) — 
(a) Renal, in 

1. Bright 's disease. 

2. Amyloid disease. 



EXAMINATION OF THE PATIENT 163 

3. Malignant growths. 

4. Tuberculosis. 

5. Eenal calculi. 

6. Cystic disease of the kidney. 

7. Abscess. 

8. Eenal embolism. 

9. Hydatids. 

10. Acute febrile processes. 

11. Purpura hemorrhagica. 

12. Traumatism involving the kidney. 

13. Ingestion of medicines, such as turpentine, cantharides, 
arsenic, etc. 

(b) Vesical, in 

1. Stone in the bladder. 

2. Cystitis. 

3. Neoplasms of the bladder. 

(c) Urethral, in 

1. Foreign bodies. 

2. Acute gonorrhea. 

3. Neoplasms. 

4. Traumatism. 
Pyuria (pus) — 

(a) Renal, in 

1. Pyelonephritis. 

2. Pyelitis. 

3. Cancer. 

4. Tuberculosis. 

5. Nephritic abscess. 
(&) Vesical, in 

1. Cystitis (colicystitis). 

2. Vesical stone. 

3. Ulceration. 

4. Tuberculosis. 
(c) Urethral, in 

1. Gonorrhea. 

2. Urethritis. 

3. Rupture of abscess in urinary passages. 
Peptonuria, in — 

1. Croupous pneumonia. 

2. Bronchopneumonia. 

3. Empyema. 

4. Phthisis pulmonum. 



164 DISEASES OF CHILDREN 

5. Epidemic cerebrospinal meningitis. 

6. Typhoid fever. 

7. Scarlet fever. 

8. Malaria. 

9. Erysipelas. 

10. Purpura hemorrhagica — diverse forms. 

11. Scurvy. 

Bacteriuria (pathogenic) is the result of infection by the 

1. Gonococcus. 

2. Tubercle bacillus. 

3. Colon bacillus. 

4. Strepto- or staphylococcus. 

Parasituria — 

1. Distomum hematobium. 

2. Filiaria. 

3. Hooklets of echinococcus. 

THE GENITALIA 

In the male child we should look for abnormalities of the penis 
(malformations, adhesions of the prepuce, phimosis, overstretched 
prepuce from masturbation, faulty location of the urethral orifice, 
urethral discharge), scrotum and its contents (tumefactions, unde- 
scended testicles). 

Scrotal tumefactions — 

1. Communicating with abdominal cavity, in hernia; hydrocele; 

and, higher up in the inguinal canal, partly descended testicle. 

2. Noncommunicating with abdominal wall, in orchitis (occasion- 

ally with parotitis), epididymitis, syphilis, tuberculosis, cysts, 
and malignant growths of testicle. 

3. Dropsical effusions, of renal or cardiac origin or edema from 

circulatory disturbance in the spermatic cord. 

4. Local scrotal inflammation, in abscess, erysipelas, gangrene; 

sebaceous cysts; traumatism. 
In the female we should note the presence of labial hernia or hema- 
toma, vaginal discharge or deposits (in diphtheria and noma) ; en- 
larged clitoris or preputial adhesions ; atresia vaginae ; abnormalities 
of the hymen (imperforate). 

Vulvovaginal discharge — 

1. Mucous, white, in simple catarrhal vulvovaginitis (from lack 
of cleanliness; irritating urine). 



EXAMINATION OF THE PATIENT 165 

2. Purulent, yellow, or yellowish-green, in gonorrheal vulvovagi- 

nitis or infection by other microorganisms (e. g., streptococcus 
in exanthematous diseases) ; cervicitis. 

3. Hemorrhagic, in hemorrhagic diathesis (in the newborn and in 

older children) ; in vulvovaginitis with erosions of the mucous 
membrane (sometimes after severe local treatment) ; prolapse 
of the urethra ; neoplasms ; menstruatio precox. 

THE RECTUM 

Abnormalities of the rectum can readily be detected by inspection 
(sometimes with the aid of proctoscope) and digital examination. 
We should look for concrylomata, fistula?, prolapsus, hemorrhoids, 
polyps, prolapse of intussuscepted intestine, fissures, piirwornis, for- 
eign bodies and discharges. 

Rectal discharges — 

1. Mucous, mucopurulent, and slightly bloody, in simple procti- 

tis ; rectal fissure or fistula ; colitis. 

2. Purulent, in communicating ischiorectal abscess; gonorrheal 

proctitis; impacted foreign body. 

3. Hemorrhagic, in hemorrhoids; polyps; dysentery; ulcerative 

proctitis (tuberculous, or otherwise); intussusception; pro- 
lapsus recti; hemorrhagic diathesis. 

THE VERTEBRAL COLUMN 

The vertebral column of the infant under six months is quite 
straight, except for a slight dorsal curve. As the child grows older 
and attains the power of sitting, standing and walking, we soon find the 
dorsal region of the spinal column curving posteriorly and the cervical 
and lumbar regions anteriorly — compensatory curvatures. At first 
these curves disappear in the recumbent posture, but they become per- 
manent at about the age of six. The normal spinal column is per- 
fectly movable. 

In the physical examination of the spinal column we note the pres- 
ence of: 
Deformities (lordosis, kyphosis and scoliosis) — 

1. Congenital, in osteogenesis imperfecta, etc.; cervical rib. 

2. Habitual, or postural from faulty posture; the effect of super- 

encumbrance (carrying of heavy weights upon the back or 
shoulders). 
3'. Static, the result of oblique pelvis, e. g., congenital or acquired 
shortening of one lower extremity as in hip-joint disease. 



166 DISEASES OP CHILDREN 

4. Tuberculous, in vertebral caries. 

5. Neuromuscular, in muscular insufficiency (to which belongs also 

rachitic deformity of the spine), or paralysis, e.g., poliomyeli- 
tis ; pseudoparalysis. 

6. Clefts, usually congenital, e. g., spina bifida. 

Tumors — 

1. Congenital, teratomas; hernial protrusions. 

2. Acquired, in vertebral caries, osteoma. 

Stiffness' 1 ' (with or without pain) — 

1. Central, in meningitis; meningeal irritation {e.g., apex pneu- 

monia; hydrocephaloid) ; encephalitis. 

2. Spinal, in disease of the spinal cord (e. g., spinal meningitis, 

myelitis) ; in trauma or disease of the vertebrae or articulation 
{e.g., vertebral caries, spondylarthritis). Also cervical rib; 
osteoma. 

3. Neuromuscular, in neuralgia ; myalgia ; myositis. 

THE EXTREMITIES 

The extremities should be examined with a great deal of care — in- 
spected, measured, palpated, percussed — since their anomalies in form 
and disturbances in function, etc., furnish most instructive informa- 
tion not only as to the existence of local disease, but also as to gen- 
eral systemic affections, preeminently those of the nervous- system. 

Shortness of — 

1. Single limbs, in paralytic, hysterical or traumatic {e.g., after 

fracture) contractures; hip- joint disease; congenital deformi- 
ties; septic processes. 

2. All extremities, in achondroplasia (as compared with the long 

trunk). 

Curvatures — 

1. Congenital, in divers congenital malformations {e.g., osteogen- 

esis imperfecta; osteomalacia; achondroplasia). 

2. Acquired, after fractures; in syphilis; rachitis; tuberculosis. 

Tumefactions — 

1. Diaphyseal, tuberculous and nontuberculous, in periostitis; 
osteitis; osteomyelitis; syphilis; exostosis; malignant growths; 
after fracture. 



See also "Attitude of the Head and Neck," and "Spondylitis." 



EXAMINATION OF THE PATIENT 167 

2. Epiphyseal, the same as in diaphyseal, also in rachitis; Bar- 
low's disease; arthritis deformans; rheumatic affections; sep- 
tic arthritides; hemarthrosis (hemophilia, peliosis rheumatica) ; 
synoA'itis; bursitis; "intermittent hydrops." 

Muscular Weakness, "naccidity" (with or without atrophy) — 

1. Without true paralysis, in pseudoparalysis of syphilitic origin 

(upper extremities); Barlow's disease; amyatonia ; osteomye- 
litis; osteomalacia; polyarthritis and myositis; traumatism of 
the muscles or bones (dislocation or fracture); progressive 
muscular atrophies (muscular and neurospinal types) ; idiocy 
(especially amaurotic family idiocy) and cretinism; rachitis 
and muscular debility after prolonged sickness (in bed) ; hys- 
teria. 

2. With paresis or paralysis, in poliomyelitis (early) ; myelitis 

(the muscular involvement depending upon the seat of the 
lesion in the cord); Landry's paralysis; spinal meningitis; 
chronic polyneuritis (usually bilateral and symmetrical) from 
various causes; birth palsies. 

Muscular Contracture, "spasticity" (with or without atrophy) — 

1. Without true paralysis, in trismus and tetanus traumaticus 

and neonatorum; meningismus; early stage of meningitis; 
tetany; pseudotetany ; tetanism (q.v.,); eclampsia infantilis; 
myotonia (Thomsen) ; catalepsy; hysteria; trichiniasis; hydro- 
cephaloid. 

2. With paresis or paralysis, in all forms of cerebral paralysis 

(cerebral hemorrhage, embolism, abscess, tumor, sclerosis, tu- 
berculosis, encephalitis, porencephalia, hydro- or microcephal- 
ous, etc.) ; myelitis (late stage) ; spastic spinal paralysis; amyo- 
trophic lateral sclerosis anterior poliomyelitis (late). 

Spasmodic movements" — 

1. Intention tremor, in disseminated sclerosis ; ataxia heredita- 

ria ; spastic cerebral paralysis ; myotonia congenita. 

2. Irregular shaking, in cerebral hemorrhage; tumor, encephalitis; 

hydrocephalus; all forms of meningitis; toxic neuritis, espe- 
cially diphtheritic and uremic; hysteria; Jacksonian epilepsy; 
idiocy; torsion spasm. 

3. Fibrillary twitching, in progressive muscular atrophy; acute 

febrile diseases; neuroses ; strychnine poisoning. 

*See also "Convulsions," p. 669. 



168 DISEASES OF CHILDREN 

4. Athetoid movements, in chronic brain affections, especially of 

the internal capsnle. 

5. Choreiform movements, in all forms of chorea; spasmus nutans; 

spastic cerebral paralysis; paramyoclonus multiplex; hysteria; 
tic ; lethargic encephalitis. 

Paralysis — 

(a) Unilateral — 

1. Upper and lower, in lesions of one cerebral hemisphere, e. g., 

cerebral hemorrhage, embolism, abscess ; tumor, sclerosis, 
encephalitis, meningitis, depressed fracture, porencephalia, 
etc. ; poliomyelitis. 

2. Upper, in unilateral cerebral lesion of the arm center (e. g., 

embolism, tubercle, etc.) ; unilateral spinal lesion of the 
cervical region (e.g., incipient spondylitis, etc.) ; trauma- 
tism to the brachial plexus (e. g., birth palsy) ; poliomyeli- 
tis; regressive stage after hemiplegia. 

3. Lower, in unilateral cerebral lesion of the leg center (same 

as in upper) ; unilateral spinal lesion in the lumbar region; 
trauma of the lumbar plexus; poliomyelitis. 

(b) Bilateral — 

1. Upper and lower, in bilateral lesions of the brain (cortex, 

pons, or medulla), e.g., intracranial hemorrhage, multiple, 
growths, especially tuberculous and syphilitic, disseminated 
sclerosis, etc.; spinal sclerosis; spinal meningitis; polio- 
myelitis; Landry's paralysis (late) ; progressive muscular 
atrophy (late) ; amyotrophic lateral sclerosis (late) ; syr- 
ingomyelia (late); multiple neuritis; amaurotic family 
idiocy (late). 

2. Upper, in double trauma of the brachial plexus or individual 

cords (e.g., compression in instrumental delivery; trans- 
verse cervical myelitis) ; poliomyelitis; Landry's paralysis 
(early) ; bilateral cerebral lesions of the arm centers; syr- 
ingomyelia (earh'). 

3. Lower, in bilateral trauma of the lumbar plexus or its main 

branches ; transverse lumbar myelitis ; transverse dorsal 
myelitis (late) ; spastic spinal paralysis; hereditary ataxia 
(late) ; tabes dorsalis (late) ; polyneuritis, especially diph- 
theritic (early) ; amyotrophic lateral sclerosis (early) ; pol- 
iomyelitis ; bilateral cerebral lesions of the leg centers ; 
hydrocephalus. 



EXAMINATION OF THE PATIENT 169 

Localized paralysis of principal muscles concerned in movements of 
the extremities and their nerve supply— 
(a) Upper extremities* — 

1. Trapezius (spinal accessory nerve) : Sinking of shoulder 

downward and forward; rotation of scapula outward and 
upward; elevation of shoulder imperfect. 

2. Serratus magnus (long thoracic nerve): Slight rotation of 

scapula; difficulty of raising arm above shoulder; deep 
furrow between scapula and vertebras on moving arm up- 
ward. 

3. Pectorales (anterior thoracic nerve) : Impaired abduction 

of upper arm ; placing of affected hand on healthy shoulder 
impossible. 

4. Teres major and subscapular (subscapular nerve) : Loss of 

inward rotation of arm. 

5. Infraspinatus (suprascapular nerve) and teres minor (axil- 

lary nerve) : Loss of outward rotation of arm. 

6. Latissimus dorsi (subscapidar nerve) : Impaired abduction 

of arm; inability to place hand on sacrum. 

7. Deltoid (circumflex nerve) : Inability to elevate arm ; atro- 

phy. 

8. Biceps and brachialis anticus (musculocutaneous) : Inability 

to flex forearm, when in supination; inability to supinate 
forearm, when flexed. 

9. Supinator longus and brevis (musculo spiral nerve): Weak- 

ened flexion when forearm is half -pronated ; inability to su- 
pinate with forearm extended and pronated. 

10. Triceps and the extensors (musculo spiral nerve, "radial 

paralysis") : Inability to extend forearm (in triceps pa- 
ralysis) ; hand-drop in flexed position; flexion of fingers; 
impaired abduction and adduction (paralysis of the ex- 
tensors) ; impaired sensation along radial side ; atrophy. 

11. Flexor carpi idnaris, profundus digitorum, minimi digiti, 

and inner head of brevis pollicis; the interossei, lumbricalis, 
palmaris brevis (ulnar nerve, "ulnar paralysis") : Claw- 
like deformity of hand. 

12. Pronator radii teres, pronator quadratics, palmaris longus; 

flexors carpi radialis, sublimis digitorum, profundus digi- 
torum, and longus pollicis (median nerve, "median paral- 
ysis"): Abolition of power of pronation; inability to flex 



*See also "Birth Palsy," p. 210. 



170 DISEASES OF CHILDREN 

terminal phalanges and thumb ; objects can be grasped 
with the last three fingers only; trophic and sensory dis- 
turbance. 

(6) Lower extremities — 

1. Gluteus maximus einel minimus (gluteal nerve): Difficulty 

to abduct thigh ; to walk uphill ; to rise from sitting pos- 
ture : impairment of circumduction and inward rotation, 
and walking; toes are turned inward. 

2. Anterior muscles of thigh, except tensor vaginae femoris 

(anterior crural nerve, " crural paralysis"): inability 
to flex thigh on trunk and to flex trunk when in recumbent 
posture ; to extend leg when flexed ; difficulty to stand or 
walk, or to rise from kneeling posture. 

3. Obturator externus einel the abductors (obturator nerve): 

Impaired adduction and outward rotation of thigh; ina- 
bility to cross legs. 

4. Biceps, semimembranosus, semitenelinosus — the flexors of 

knee (great sciatic nerve): Inability to flex knee; difficult 
locomotion; leg inverted or everted. 

5. Gastrocnemius, sole us, and plantaris — the extensors of the 

foot (internal popliteal nerve): Inability to extend (plan- 
tar flexion) of f oct. to stand on tiptoe ; difficulty in walk- 
ing; foot everted, ankle lowered (talipes calcaneus). 

6. Peroneus longus (musculocutaneous) : Foot inverted; plan- 

tar arch flattened (flat foot). 

7. Tibialis anticus, and extensor longus digitorum — flexors of 

foot (anterior tibial nerve): Impaired flexion; abduction 
and adduction (talipes equinus). 

8. Peroneus brevis, and tibialis posticus (posterior tibial nerve) : 

Inability to adduct or abduct foot without flexion or ex- 
tension. Talipes valgus in tibial paralysis ; talipes varus 
in peroneal paralysis. 

Peculiarities of gait — 

1. Dragging, in multiple sclerosis; spastic spinal paralysis; poli- 

omyelitis involving both legs; amyotrophic lateral sclerosis; 
hemiplegia, and cretinism. 

2. Straddling, in tabes dorsalis. 

3. Staggering, reeling, in multiple neuritis; hereditary ataxia; 

cerebellar disease. 

4. Waddling, in progressive muscular dystrophy; bilateral dislo- 

cation of the hips; rachitis. 



EXAMINATION OF THE PATIENT 171 

5. Hobbling, in osteomalacia. 

6. Shuffling, in hysterical paralysis. 

Tendon reflexes — 

(a) Knee-jerk 1 — 

1. Exaggerated, in spinal or cerebral paralysis, associated with 

"spasticity" of the muscles (see p. 167) ; also in trans- 
verse myelitis affecting the spinal cord above the second 
lumbar vertebra; cerebellar disease; general nervousness. 

2. Diminished or lost, in spinal or neural affections associated 

with "flaccidity" of the musculature (see p. 167) ; also 
in transverse myelitis below the second or third lumbar 
vertebra; hereditary ataxia; "meningismus" (early stage). 

(b) Ankle clonus 2 — 

1. Absent or very slight, in good health. 

2. Present, and often very pronounced, in cerebral hemorrhage ; 

spastic spinal paralysis; dorsal myelitis; disseminated lat- 
eral sclerosis; hysterical paralysis; tetanus. 

(c) Periosteal reflex* — 

1. Slight, in good health. 

2. Greatly exaggerated, in cerebral hemorrhage. 

Kernig's sign (inability to extend legs when the thighs are flexed on 
abdomen) : In divers forms of meningitis; occasionally in ty- 
phoid fever. 

Baoinski's reflex (extension of great toe with flexion of other toes 
on crossing sole of foot with index finger) : Pathognomonic 
of meningitis in children over two years of age, in organic 
hemiplegia. 

Brudzinski's sign (flexion of head upon chest produces simultaneous 
flexion of legs towards abdomen) : In meningitis and polio- 
encephalitis. 

Weight and Length of Normal Children 
An exact record of the gain or loss in weight of the patient is inval- 
uable in the diagnosis, prognosis and treatment. There is no abso- 
lute standard for the normal weight or height of a normal infant or 
older child. To a great extent it depends upon the race the child 
descends from and also upon the family disposition. Furthermore, 
the size of the child is not always an indication of its inherent vigor. 
Ordinarily boys are heavier than girls. 



1 Obtained by a sharp blow over ligamentum patellas, while lower leg hangs loosely down. 

2 Rhythmic oscillation of the foot, elicited by abruptly pressing toes upward with one hand, 
while supporting the leg with the other hand. 

3 Jerk of hand or forearm produced by a tap upon the tendons of the supinator longus and 
biceps at lower end of the radius and ulna; or of the triceps tendon, at the olecranon. 



172 



DISEASES OF CHILDREN 




Fig. 29.— Buffalo scale. 



WEEK OF WEEK OF AGE 

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Fig. 30. — Normal infant's weight chart. 



EXAMINATION OF THE PATIENT 173 









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Abdomen 




Lbs. 


In. 


In. 


In. 


In. 


1 Month 


8 


21.75 


13.75 


13.50 


13.50 


2 Months 


ioy 2 


23.25 


15.40 


14.09 


14.09 


3 Months 


12 


24.00 


15.80 


14.70 


14.70 


4 Months 


14 


24.75 


16.14 


15.30 


15.30 


5 Months 


14% 


25.21 


16.60 


15.88 


15.88 


6 Months 


15y 2 


25.75 


17.00 


16.07 


16.07 


7 Months 


16% 


26.00 


17.16 


16.90 


16.75 


8 Months 


17 


26.50 


17.37 


17.00 


17.00 


9 Months 


17% 


26.75 


17.50 


17.25 


17.25 


10 Months 


I8.1/2 


27.25 


17.66 


17.50 


17.50 


11 Months 


19% 


27.75 


17.82 


17.74 


17.75 


12 Months 


20 


29.00 


18.00 


18.00 


18.00 


14 Months 


21 


29.00 


18.16 


18.16 


18.16 


16 Months 


22% 


29.50 


18.33 


18.33 


18.33 


18 Months 


23i/ 2 


30.00 


18.50 


18.50 


18.50 


20 Months 


24 


30.50 


18.62 


18.62 


18.62 


22 Months 


24% 


31.00 


18.83 


18.83 


18.83 


24 Months 


25 


31.50 


19.00 


19.00 


19.00 


28 Months 


27 


33.00 


19.16 


19.33 


19.16 


32 Months 


29 


34.00 


19.33 


19.66 


19.33 


36 Months 


31 


35.00 


19.50 


20.00 


19.50 


Sy 2 Years 


33 


36.50 


19.71 


20.50 


19.71 


4 Years 


35 


38.00 


20.00 


2.1.00 


20.00 


4% Years 


38 


38.50 


20.21 


21.21 


20.20 


5 Years 


41 


41.50 


20.50 


21.50 


20.00 



Children over five years of age ordinarily gain about 5 pounds in 
weight and 2 inches in height yearly up to twelve years of age. 
Weight is — 

1. Diminished, rapidly, in cholera infantum; acute febrile diseases; 

athrepsia; chronic wasting diseases, especially tuberculosis, 
malignant growths and suppurative processes; diabetes. 

2. Slowly, in dyspepsia ; organic affections with slow course, e. g., 

heart and kidney diseases. (Avoid mistaking increasing weight 
from large dropsical effusion for natural gain ! ) 

3. Increased, rapidly, in adipositas; pituitary disease (Froehlich's 

syndrome) ; cretinism; anasarca. 

4. Increased, slowly, in normal health. 
Height is — 

1. At a standstill or nearly so, in infantilism; cretinism; severe 

forms of rachitis ; achondroplasia; in marked central paralysis. 

2. Increased, rapidly, in disease of the hypophysis ; acute febrile 

diseases, especially typhoid fever. 

3. Increased, slowly, in normal growth. 



CHAPTER III 

CONGENITAL MALFORMATIONS 

Congenital malformations depend upon the following causal factors : 

1. Hereditary disposition {e.g., supernumerary fingers and toes). 

2. Antenatal constitutional diseases, especially syphilis and tubercu- 
losis {e.g., hydrocephalus and spina bifida). 

3. Traumatism during pregnancy {e. g., multiple fractures and dis- 
locations). 

4. Extra- or intraabdominal pressure through pelvic deformities, tu- 
mors, etc. (<?. g., talipes). 

5. Constriction by amniotic bands {e.g., amputations). 

CONGENITAL MALFORMATIONS OF THE HEAD 

Cephalocele (Hernia of the Brain) 

Meningocele, Encephalocele, Encephalocystocele or 
Hydroencephalocele 

Congenital defects in the cranial bones permit the protrusion of 
a portion of the contents of the skull. The hernia may consist of — 

(a) Meninges (which form the hernial sac) with or without^ cerebral 
fluid — meningocele* 

(b) Meninges and brain substance — encephalocele. 

(c) Meninges and brain substance, which enclose a cavity which is 
filled with fluid and communicates with a cerebral ventricle — hydroen- 
cephalocele or encephalocystocele. 

In accordance with their location we distinguish the following forms 
of cephalocele : 

(a) Cephalocele occipitalis superior — situated above the external occip- 
ital protuberance. 

(Z>) Cephalocele occipitalis inferior — situated below the protuberance. 

(c) Cephalocele nasofrontalis — emerges from above the nasal bones. 

(d) Cephalocele nasoethmoidalis — situated below one of the nasal 
bones. 

(e) Cephalocele nasoorbitalis — appears at the inner angle of the eye. 



*Congenital meningocele is not to be confounded with acquired so-called pseudomeningocele 
or meningocele spuria s. traumatica, which is either a result of trauma during delivery or a ca- 
rious process, especially syphilis. Here the tumor is usually situated at one of the parietal bones, 
increases in size with the development of the brain or enlargement of the cleft in the bone. 

174 



CONGENITAL MALFORMATIONS 175 

The presenting tumor varies in size from a small nut to a fetal head. 
It may be fiat, sessile, hemispherical, pear-shaped or pedunculated. 
Small tumors are soft and elastic, larger ones pulsate and are often 
translucent. They enlarge during crying, and may be reduced in size 
by compression, a procedure which is usually attended by meningeal 
disturbances. By bearing in mind the characteristic signs, there ought 
to be no difficulty in differentiating cephaloceles from extracranial 
cysts, hematomas, abscesses, etc. The diagnosis may be facilitated 
by an x-ray examination, showing the edges of the opening in the bone. 
Cephaloceles may remain small and give rise to but very little dis- 
turbance. As a rule, however, they grow rapidly and produce death 
from meningitis, convulsions, or rupture, or proceed a slower course 
manifested by more or less pronounced backwardness in physical and 
mental development and other evidences of organic brain disease. 

Small cephaloceles require no surgical interference, but merely pro- 
tection against external injuries by suitable caps, etc., or gentle com- 
pression after reposition of the protrusion. Inoperable cases are those 
complicated by pronounced flattening or diminution in size of the 
skull, by hydrocephalus or other serious malformations, or where the 
cleft in the skull reaches down to the foramen magnum. In all other 
cases removal of the protruding brain is the only proper treatment, fol- 
lowed, if necessary, by osteoplastic closure of the defect in the skull. 

As the operation is not rarely successful, if performed by a skillful 
surgeon; and as the prognosis is extremely grave in large tumors if 
let alone, there is sufficient justification for early (!) surgical inter- 
ference. 

Hydrocephalus (See pp. 117, 596, 710). 

Microcephalus (See p. 707). 

CONGENITAL MALFORMATIONS OF THE FACE 

Including Those of the Palate, Mouth, Eyes, Nose and Ears 

Clefts of the Face and Lips 

1. Median, the result of nonunion of both globular processes of the 
central nasal process. This cleft is rarely extensive. 

2. Lateral (labium leporinum, harelip, clieiloschisis), produced by 
failure of union of one or both globular processes with the superior max- 
illary processes. Clefts of the upper lip may accordingly be unilateral or 
bilateral, may exist as a mere notch into the skin margin of the lip, or, 
more frequently, extend for some distance upward, involving the whole 
lip, nostril and upper jaw. It is occasionally associated with cleft palate. 



176 



DISEASES OF CHILDREN 



3. Oblique (meloschisis), arises from defective closure of the groove 
between the lateral nasal process and the superior maxillary process. 
The cleft runs as high as the lower lid. 

4. Transverse (macrostomia), as a result of patency of the groove be- 
tween the superior maxillary process and the first branchial arch (man- 
dibula). 

Occasionally fistulas and fissures are observed in the bridge of the 
nose and lower lip. 

For details of treatment the reader is referred to text books on surgery. 




Fig. 31.— Harelip. 

Cleft Palate (Palatum Fissum, Palatoschisis) 

It is due to defective union of the processes of the superior maxil- 
lary and palate bones which during intrauterine life normally grow 
inward to meet the vomer in the middle line and the intramaxillary 
bone in front to form the hard and soft palates. 

1. Complete (Uranoschisma) . — The fissure extends in the middle line 
through the uvula and the soft and hard palates, and thence through 
the alveolar process in the line of suture either on one or both sides of 
the intramaxillary bone. It is generally combined with double or single 
harelip, and is then designated "Wolf's Jaw." 

2. Partial (Uranocoloboma) . — It may involve the uvula only, or part 
of the soft and hard palates as well. Sometimes it is limited to a mere 
notching of the alveolar process on one or both sides and forms the 
continuation of uni- or bilateral harelip. 

The consequences of cleft palate, if extensive in degree, are by far 
more serious than those of cleft lip. Suction and deglutition are greatly 
interfered with. In older children the voice, articulation, sense of taste, 
smell, and hearing may all be impaired. 



CONGENITAL MALFORMATIONS 177 

The management of cleft palate is principally surgical. The earlier 
the operation is undertaken the more perfect are the results. The mode 
of feeding frequently presents great difficulty. Infants born with marked 
cleft palate who are unable to nurse have to be fed artificially either 
with the spoon or through a tube passed through the nose into the 
stomach. A vulcanized rubber plate covering the defect in the palate 
often acts admirably. 

Defects of the Mouth and Tongue 

Atresia Oris (Microstomia). — The lips may be grown together par- 
tially or completely. In the latter event an immediate plastic opera- 
tion is inevitable. Congenital microstomia should not be confounded 
with the acquired contractures of the oral orifice resulting from syph- 
ilis, gangrene, burns, etc. 

Adhaesio Linguae (Ankyloglossia, Tongue-Tie). — It is produced by 
a large and anteriorly displaced frenulum, and varies greatly in de- 
gree, the insertion of the frenulum sometimes extending so far for- 
ward as to interfere with suckling, and, later, with speech. 

The anomaly may be removed by nicking the frenulum w T ith a scis- 
sors, and further "loosening of the tongue-string" with the finger, thus 
avoiding injury to the ranine artery (dangerous in hemophilia!). The 
rare adhesion between the epithelial surfaces of the tongue and the 
floor of the mouth can be liberated in a similar manner. 

Macroglossia (Large Tongue). — Enlargement of the tongue may 
be due to a true lymphangiomatous tumor (cavernous macroglossia), 
or to a fibrous hypertrophy (fibrous macroglossia). Both forms may 
coexist. The tongue may be so markedly enlarged as to find no room 
in the mouth, and by protruding from it become bruised, chapped 
and cracked, assume such dimensions as to render suckling very diffi- 
cult or impossible, and possibly lead to a fatal issue from inanition. 
Congenital macroglossia from the aforementioned causes is not to 
be mistaken for protrusion of the tongue associated with cretinism. 
Mild degrees of macroglossia usually improve spontaneously with 
the growth of the oral cavity ; severe forms- call for removal of a wedge- 
shaped piece of the protruding tongue. 

Malformations of the Eyes 

Anophthalmus (Absence of One or Both Eyes). — This is a rare mal- 
formation. In a great many cases careful anatomic examination re- 
veals the presence of rudimentary eyes. If only one eye is absent, 
the existing eye may be perfectly normal or defective in various w T ays. 



178 DISEASES OF CHILDREN 

Microphthalmus. — An abnormally small eye causes more or less se- 
vere disturbance of vision which may in some instances be relieved 
by suitable glasses. It is sometimes associated with adhesion of the 
edges of the eyelids (ankyloblepharon, cryptophthalmus), and other 
abnormalities of the bulb, which may require surgical treatment. 

Atresia Pupillae Congenita. — Occasionally the pupillary membrane 
persists after birth and varying with its extent leads to more or less 




Fig. 32. — Bilateral congenital anophthalmia. 

grave visual defects. The fine, gray membrane may be mistaken 
for an exudation or capsular cataract. Spontaneous improvement is 
the rule. 

Cataracta Congenita. — It is usually partial, rarely complete. It may 
exist in the form of limited opacities and not be recognized until school 
age. In the complete variety the condition may present a white pu- 
pil. Zonular or lamellar cataract may be acquired during early in- 
fancy as a result of faulty metabolism or during the course of tetany. 
It often remains stationary for many years. 



CONGENITAL MALFORMATIONS 179 

Treatment. — If suitable glasses give the patient sufficient vision for 
educational and other purposes, an operation may be indefinitely 
postponed. Otherwise discission, iridectomy or lenticular extraction 
is indicated. 

Coloboma Iridis (Iridoschisma, Fissure of the Iris). — It is usu- 
ally bilateral and sometimes associated with coloboma of the choroid, 
fissure of the upper ej^elid without involvement of the external skin, 
microphthalmias, and cataract. If uncomplicated, it disturbs the vision 
but slightly. 

Irideremia (Aniridia). — Partial or complete absence of the iris usu- 
ally occurs on both sides and is associated with abnormality of the 
cornea and poor vision. The pupils are iridescent like cat's eyes, and 
owing to too strong perception of light, the affected children con- 
vulsively open and close the eyelids. The same phenomenon is often 
observed in albinism — a condition in which there is a congenital defi- 
ciency of pigment in the iris and choroid. Albinos have a blue iris 
and very fair complexion. 

Treatment. — Exclusion of superabundance of light by means of dark 
glasses or artificial diaphragm. 

Malformations of the Nose 

Adhesions Between the Turbinated Bones, Particularly the Inferior, 
and the Septum. — The adhesions may be membranous or bony, and 
not rarely associated with deflection of the septum. The treatment is 
the same as in the acquired adhesions. 

Atresia of the Posterior Nares. — The closure may be membranous 
or bony; in the latter condition there is bony union between the palate 
and the sphenoid. If the closure is only moderately firm, it can be 
perforated by a stout probe or galvanocautery. Firm bony unions 
giving rise to difficult suckling call for the employment of chisel and 
mallet or trephine, using finger in the nasopharynx as a guide to pre- 
vent the instrument from penetrating too deeply. 

Malformations of the Ears 

Fissures and Fistulas of the Ear. — Fissures (beneath the tail of the 
helix) and fistulas (in front of and above the tragus) are occasionally 
observed, especially in connection with other congenital malformations. 
Deep fistulae sometimes secrete a serous fluid not rarely causing intracta- 
ble eczema and requiring operative interference. 

Auricular appendages in the form of scattered round or oblong, 
smooth or warty pieces of cartilage are not rarely found in front 
of the ear. They can readily be removed by knife or electric cautery. 



180 DISEASES OF CHILDREN 

Ear prominence is a malformation which can often be remedied in 
the newborn by keeping the ear properly bandaged for several weeks. 
Sometimes it calls for a slight operation. 

Atresia auris, absence of the auditory meatus, is most frequently 
complete, involving the cartilaginous as well as the bony portion of 
the canal. Moreover, there is usually also an abnormal tympanic mem- 
brane. Hence very little benefit can be expected from operative inter- 
ference. 

All sorts of ear deformities are encountered in connection with idiocy 
and the allied mental deficiencies (q.v.). 

MALFORMATIONS OF THE LARYNX AND TRACHEA 

Congenital Diaphragm of the Larynx. — The glottis is more or less 
occluded by a membrane running transversely across the vocal cords. 
The symptoms stand in direct relation to the size of the remaining 
opening. 

In marked cases the membrane should be excised after preliminary 
tracheotomy. 

Laryngocele and Tracheocele (Aerocele). — The tumor is situated 
laterally or in the median line. It increases in size on coughing or 
crying and diminishes on pressure. 

The treatment consists of excision of the cyst and closure of the 
communication with the respiratory tube. 

Stridor Congenitus (Child-Crowing). — This congenital anomaly is not 
to be confounded with laryngospasmus (spasmus glottidis, see p. 677) 
which is an acquired affection and forms a symptom of spasmophilia 
(q.v.). 

The etiology is still indefinite, although in a number of cases the 
stridor could be traced to malformation of the epiglottis and hypertro- 
phy of the thymus gland. 

Stridor congenitus is manifested by a loud, crowing inspiration, ac- 
companied by retraction of the jugulum and epigastrium. It is free 
from cyanosis or any systemic disturbance, and usually subsides spon- 
taneously in the course of a year or so. 

MALFORMATIONS OF THE NECK 

Fistula Colli Congenita. — This is a rare anomaly, the result of de- 
fective closure of the second and third branchial arches. The fistula 
is situated either laterally immediately above the sternoclavicular ar- 
ticulation, or medianly at a varying level between the hyoid bone 
and the jugulum. The fistula becomes apparent by its fine, pinhead- 



CONGENITAL MALFORMATIONS 181 

sized opening with an irregular, moist surface. By passing a fine probe 
the fistula is found to end either blindly or in the pharynx or esopha- 
gus. So long as its track is free, the fistula gives rise to no serious 
symptoms. Its occlusion, however, is associated with danger of re- 
tention of the mucoid secretion and cyst formation. Hence the indi- 
cation for complete extirpation of the fistulous canal. 

Branchial Appendages. — These occur in the shape of warts, nipples 
or mushrooms, along the margin of the sternomastoid, between the 
sternoclavicular region and the hyoid bone, consist of skin alone or of 
skin and cartilage, and are frequently associated with auricular at- 
tachments (q.v.). They cause no annoyance except from a cosmetic 
point of view. They are readily removable and nonrecurrent. 

Branchiogenetic Cysts, — The seat of these variously sized (from a 
small nut to a hen's egg), elastic, serous, seromucous, sebaceous, some- 
times dermoid cysts is the anterior region of the neck (in the middle 
line or at the side). The cyst contents may become purulent through 
infection or sanguinolent through involvement of a blood vessel. As- 
piration is a useful aid in the diagnosis, and extirpation of the cyst 
the only rational mode of treatment. 

Hygroma Cysticum Colli Congenitum (Lymphangioma Cysticum). — 
This tumor consists of a number of small or large communicating or 
noncommunicating cysts. It varies in size from a slight swelling under 
the lower jaw or over the clavicle to an enormous tumor embracing 
the whole neck, and extending downward to the chest and upward 
to the face. It may even involve the mouth, throat, base of the cranium 
and mediastinum. In the latter event the prognosis is extremely 
grave. As the removal of large tumors is attended by great diffi- 
culties, it is often justifiable first to try aspiration with subsequent 
injection of iodine or incision and antiseptic packing. Small hygromas 
should unhesitatingly be extirpated. 

Cervical Rib. — The supernumerary rib is a hard, bony clasp which be- 
gins usually at the seventh or sixth cervical vertebra and either ends there 
as a small protuberance or continues farther to join the first thoracic 
rib or even the sternum. It may be unilateral or bilateral (Fig. 33). 
The symptomatology depends upon the degree of pressure exerted by 
the rib upon the neighboring structures, especially the subclavian 
artery and some branches of the brachial plexus (neuritis) ; sometimes 
there is dilatation of the pupil owing to pressure paralysis of the cervi- 
cal sympathetic nerve. As a rule, the symptoms do not become mani- 
fest until the child has reached the age of eight years or later. The 
diagnosis must rest chiefly upon a very careful roentgen-ray examina- 
tion. A nine-year-old girl under my observation was for two years 



182 



DISEASES OF CHILDREN 



treated for cervical spondylitis without the slightest benefit, until at 
last an exact radiogram disclosed the presence of a cervical rib on 
the right side. 

Treatment.— "Where the symptoms are mild, palliative therapeutic 
measures, such as rest, massage and electricity for the relief of pain 




Fig. 33. — Large asymmetrical cervical ribs; neuritis and vascular disturbances in 
the right arm. (Dr. A. Church.) 

usually suffice. On the other hand, cases presenting severe vascular, 
nervous and trophic disturbances call for extirpation of the^ super- 
numerary rib, an operation demanding great surgical skill. 



MALFORMATIONS OF THE THORAX 

Defects of the Sternum. — Partial or complete absence or smaller con- 
genital clefts of the sternum are of rare occurrence. They give rise 
to hernial protrusions of the lung, which if small in size are apt to 
be mistaken for soft tumors or abscesses. Lung hernia is reducible on 
pressure, changes in size and shape with respiration, and is frequently 
associated with paroxysms of coughing. 

Among the diverse deformities of the sternum, congenital, non- 
rachitic ''funnel chest" is deserving of special mention. It differs 
from acquired rachitic funnel-shaped chest by the absence of other 
rachitic deformities. 

Anomalies of the Ribs. — One or more ribs may be absent or rudi- 
mentarily developed. The intervening space is filled with membrane. 



CONGENITAL MALFORMATIONS 183 

There may also be accessory ribs (see "Cervical Rib," p. 181, or sev- 
eral ribs may be united. 

Defects of the Thoracic Muscles. — Congenital, partial or total ab- 
sence of one or several of the thoracic muscles is apt to be mistaken 
for progressive muscular dystrophy. The former, however, is uni- 
lateral, while the latter is bilateral. Secondary scoliosis is apt to 
follow the congenital muscular defects. 

All the aforementioned malformations of the thorax require some 
mechanical contrivance, to prevent either injury to the internal struc- 
tures or secondary deformities. 

MALFORMATIONS OF THE ALIMENTARY TRACT 

Atresia Esophagi. — Congenital esophageal strictures are very rare. 
They give rise to difficulty of swallowing and immediate regurgita- 
tion of the food through the mouth and nose. Introduction of a 
bougie shows the seat of the obstruction. 

The treatment is the same as in acquired esophageal strictures. Ow- 
ing to the absence of true scar tissue in the congenital form, the pros- 
pects of recovery are brighter. 

Stenosis Pylori Congenita. — (See p. 242.) 

Congenital Stenoses and Atresia of the Intestines 

Any portion of the intestines may be congenitally malformed or 
completely obliterated. Partial stenosis is most frequently observed 
in the small intestine, while complete atresia occurred more frequently 
in the rectum and anus. Pathologically it is found that the lumen of 
the intestine above the occlusion is widely dilated, while that below it is 
more or less collapsed. 

The symptoms vary with the seat of the lesion. The higher the 
stenosis, the earlier and more pronounced the vomiting, the larger 
the quantity of the meconium, and the more marked the dyspnea, 
and eventually the cyanosis as a result of compression of the thoracic 
organs by the highly distended stomach. 

On the other hand, the lower the stenosis, the more fecal the 
. vomiting, the greater the meteorism, and the more marked the dis- 
turbances of the bladder and kidney (partial or total anuria as a 
result of compression of the ureters by the highly distended intes- 
tines). In stenosis of the duodenum the vomitus contains bile sub- 
stances. 

Associated with the local symptoms of intestinal stenosis are: dry 
tongue, subnormal temperature, rapid emaciation, pinched features of 



184 



DISEASES OF CHILDREN 



the face, and collapse. Death usually takes place within a week. 
Where the stenosis is only partial and slight, the child may linger for 
months and ultimately recover. 

In mild cases the treatment should be symptomatic, principally to 
relieve constipation and to mitigate the pain and agony. Surgical 
intervention as a last resort. 

Congenital Hypertrophy and Dilatation of the Colon 

(Megacolon Congenitum, Hirschsprung's Disease) 

This congenital affection should not be mistaken for acquired dila- 
tation of the large bowel associated with intestinal atony from various 
causes. 




Fig. 34. — Moderate degree of megacolon congenitum or Hirschsprung's disease, in a 

child three vears old. 



The congenital dilatation is manifested soon after birth by retention 
of the meconium, although the child is otherwise apparently healthy 
and free from congenital stenosis of the anus or rectum. Intestinal 



CONGENITAL MALFORMATIONS 



185 



irrigation brings forth but a small quantity of feces. The infant is 
restless and constipated, and its abdomen gradually becomes greatly 
distended. Some time later the constipation is followed by more 
or less copious diarrhea due to intestinal irritation from retained feces. 
After expulsion of the stool and gas, the abdomen is reduced in size, 
but after a short time it again becomes distended, giving rise to the 
aforementioned symptoms. Most infants succumb early to the disease, 
from interference with the thoracic organs or autointoxication by 




Fig. 35. — Congenital absence of anus and rectum and of scrotum and its contents. 

the decomposing intestinal contents; others may live longer and in 
rare instances even entirely recover. 

Postmortem examination reveals either of the following conditions: 
(1) Simple dilatation and often lengthening of the colon; (2) ectasis 
of a section of the colon with or without compensating dilatation or 
hypertrophy of the adjoining portions; (3) general enlargement of the 
intestinal lumen and hypertrophy of its walls. The hypertrophy usu- 
ally involves the longitudinal and circular muscular fibers. 

The treatment is chiefly symptomatic (see "Constipation") ; in severe 
cases surgical intervention. 



186 



DISEASES OF CHILDREN 

Atresia of the Rectum and Anus 



Atresia Ani Proper (Imperforate Anus). — The rectum is normal and 
ends blindly into the completely closed anus. There may not be the 
slightest indication of an anus, or the latter is indicated by a few 
comb-like prominences, a small fossa, or a round indulation. 

Atresia Recti. — The anus is normally developed, but the rectum ends 
blindly somewhere higher up in the canal. 




Fig. 36. — Stomach and intestines of case shown in Fig. 35, showing ending of colon 
in a blind pouch filled with meconium. 

Atresia Ani et Intestini Recti. — In this condition the anal orifice is 
absent and the rectum is arrested in its development higher up, usu- 
ally in the region of the sacroiliac symphysis. 

Atresia Ani Complicata, — There is atresia of the anus, and the 
rectum terminates either (1) in the bladder (atresia recti vesicalis); 
(2) in the vagina (atresia recti vaginalis), or somewhere in the urethra 
(atresia recti urethralis). 

Atresia Recti cum Fistula. — The anus proper is occluded; the rec- 
tum ends blindly, but is connected with the outer skin by a fistulous 



CONGENITAL MALFORMATIONS 187 

tract. The anal orifice is thus located in an abnormal position in the 
perineum, vulva, scrotum, etc. 

The diagnosis of imperforate anus or rectum usually presents no 
difficulty. Imperforate anus can readily be made out by inspection. 
Absence of meconium in the presence of a normal anus indicates that 
the defect is somewhere higher up. Digital or instrumental exam- 
ination rarely fails to locate the seat of obstruction. Atresia ani com- 
plicata may be detected by the presence of meconium in the urine 
or by continuous escape of feces from the abnormal communications. 
The latter symptom is indicative also of atresia recti cum fistula, which 
can readily be seen. 

Imperforate anus and rectum are the only two conditions giving 
rise to immediate more or less grave symptoms. The child passes no 
meconium, appears restless, strains, cries, its abdomen is distended, 
it suffers from dyspnea, and vomits occasionally. If not relieved, it 
succumbs within a week from rupture of the intestines and peritonitis. 
Prompt operative interference is therefore imperative. If the ob- 
struction is in the anus, or in the lower part of the rectum, puncture 
or incision with consecutive dilatation will often suffice to effect a 
cure. Whenever the point of the atresia cannot be discerned, an arti- 
ficial anus should be made for quick relief, postponing the curative 
measures for later. An operation should be postponed also in all 
other forms of atresia ani or recti, where the escape of meconium is 
not entirely interfered with. 

DEFECTS OF THE ABDOMINAL PARIETES 

Diastasis Recti Abdominis. — Lozenge-shaped separation of the ab- 
dominal wall, extending from the xiphoid to the umbilicus, is con- 
genital in nature and due to defective closure of the deep layers of 




Fig. 37. — Diastasis recti abdominis in an amaurotic idiot. 



188 



DISEASES OF CHILDREN 



the abdominal coverings. It is sometimes associated with umbilical 
hernia. 

The symptoms make their appearance when the child is able to 
run and jump, and consist of sudden attacks of colic (not to be mis- 
taken for enteralgia!), uneasiness in the epigastric region, pallor, etc., 
which subside when the child is perfectly at rest. These paroxysms 
are due to partial incarceration of the stomach in the abdominal slit, 
and should be remedied by bringing and keeping the separated recti 
muscles together by means of plaster straps or suitable bandage. 

Congenital Umbilical Hernia 

(Hernia Funiculi Umbilicalis, Exomphalos, Omphalocele 
Congenita, Ectopia Viscerum, Amnion Navel) 




Fig. 38. — Congenital umbilical hernia. 

As a result of faulty development of the abdominal coverings, in- 
stead of an umbilicus, a variously sized, sac-like dilatation is occa- 
sionally observed which may contain intestinal loops, the stomach, 
liver, spleen, etc. The hernial sac is composed of the amnion and pari- 



CONGENITAL MALFORMATIONS 



189 





Fig. 39. — Congenital femoral hernia. Fig. 40. — Ectopia viseerum. 




Fig. 41. — Thoracoabdominopagus with prolapse of intestines. 



190 



DISEASES OF CHILDREN 



etal peritoneum. At birth the contents of the sac can usually be rec- 
ognized through the thin, transparent membranes, but small protru- 
sions into the cord are apt to be overlooked, and carelessly tied off 
with the umbilical rest. If there is considerable eventration, the in- 




Fig. 42. — Skiagram of thoracoabdommopagus. (Same as Fig. 41.) 

fants die early from rupture of the sac and peritonitis. The first indi- 
cation therefore is to replace the prolapsed structures into the ab- 
dominal cavity and to keep them there by means of a suitable bandage. 
In this manner small hernias not rarely subside spontaneously. Large 
hernias should be treated by a radical operation. 

Persistence of the Ductus Omphalomesentericus 

(VlTELLOINTESTINAL DUCT) 

Physiologically, the omphaloentericus duct, the embryonic tubular 
communication between the intestinal canal and the germinal vesicle, 



CONGENITAL MALFORMATIONS 191 

disappears at about the eighth week of fetal life. Occasionally the 
duct is not obliterated, and leads to the following principal abnor- 
malities: 

1. A fine fistula at the umbilical ring, forming a communication 
between the bowels and the exterior, and secreting a cloudy fluid con- 
taining a trace of fecal matter. 

2. A hernial protrusion through the umbilicus in the form of a red 
finger-shaped tumor which is usually composed of the prolapsed walls 
of the fistula, but sometimes of intestinal loops. 

3. Open Meckel's diverticulum. It is a blind appendage of the lower 
part of the ileum, and may be free or united with the umbilicus by 
a solid cord. Under certain conditions it may enter a hernial sac and 
here become strangulated. It may produce "ileus" by incarcerat- 
ing some loops of the intestines, and give rise to local intestinal in- 
flammation closely resembling that of appendicitis. 

Persistent omphaloenteric duct may be mistaken for: (1) persis- 
tent urachus — on examination with the catheter it can be reached 
through the bladder; the secretion is composed chiefly of urine; (2) 
sarc omphalos — has no fistular opening. 

Fine fistulas frequently close after repeated cauterization with the 
caustic stick. Wherever the prolapse is very marked, or in cases 
associated with open diverticula, a radical operation is imperative, 
since their presence is always a menace to life. 

Urachus Fistula 

(FlSSURA VESICiE UmBILICALIS) 

Persistent urachus — the duct through which the urinary bladder 
communicates with the allantois — gives rise to a fistulous tract which 
ends at the umbilicus. On pressure a small hernial tumor arches 
forward and secretes a clear or turbid fluid, composed of urine alone, 
or urine, mucus and pus. If the fistula is large, the flow may be con- 
tinuous. It may give rise to cystitis and even pyelonephritis compell- 
ing early operative procedures. The first attempt at a cure should 
be directed to making the natural outlet free {e.g., cure of phimosis). 
Small fistulas often yield to cauterization and continued pressure with 
a bandage. If this fails, the walls of the sinus should be freshened and 
sutured. 

Its differentiation from persistent ductus omphalomesentericus has 
been emphasized above. 



192 DISEASES OF CHILDREN 

MALFORMATIONS OF THE GENITOURINARY ORGANS 

Congenital Abnormalities of the Kidneys 

The kidneys, like all other parts of the body, are subject to defec- 
tive embryonic development. They may be abnormal in size, shape 
(horseshoe), and number. This is of clinical importance, since mal- 
formed kidneys are more easily affected by disease, especially tuber- 
culosis, than normal organs. Congenital absence of one kidney has 
been observed once in about 4,000 autopsies. Furthermore, it is usually 
found that whenever one kidney is absent, the other one is in a more or 
less diseased condition, chiefly greatly hypertrophied. Congenital dis- 
placement of the kidney (both kidneys on one side; in front of the 
vertebral column; low down in the pelvis) is very apt to cause many 
diagnostic errors. 

Malformations of the Ureters 

Abnormal ureteral openings, as to size and position, are of great 
clinical significance. In the male the ureter may terminate into the 
sphincter of the bladder, the prostatic portion of the urethra, or in 
the seminal vesicles, and by interference with the flow of urine give 
rise to dilatation of the ureter and renal pelvis and atrophy of the renal 
parenchyma. In the female the ureter may end in the sphincter of 
the bladder, in the urethra, or in the vagina. More serious than mis- 
placement is absence or atresia of the ureter. Either one of these latter 
conditions invariably produces hydronephrosis, compelling extirpation 
of the affected kidney. Double ureter, if free from any other anomaly, 
is not attended by any pathologic phenomena. 

Malformations of the Bladder 

Ectopia Vesicae Congenita, Cleft Bladder, Fissure of the Bladder, 
Extrophy Vesicae. — Cleft bladder arises from arrest of development of 
the anterior walls of the bladder and abdomen, and often also of the 
symphysis. It may be partial or complete. In the complete variety 
the posterior vesical wall protrudes as a round, moist, bright-red tu- 
mor, through a gap in the abdominal wall, situated in the median 
line between the umbilicus and the urethra. The mass is marked by 
two small tubercles on both sides — the orifices of the urethra — from 
which the urine dribbles continuously. In the male this is associated 
with epispadias of the rudimentary penis; in the female the clitoris 
is clefted, the labia are widely separated, and the urethra and vagina 
more or less defective. Eversion of the bladder is often complicated 
also by other malformations of the body, and in the majority of 



CONGENITAL MALFORMATIONS 193 

instances leads to early death. Partial ectopia vesicas offers a more 
favorable prognosis, particularly if a plastic operation is resorted to 
early. Temporary relief may be obtained from a suitable urinal held 
in place by means of a truss. 

Malformations of the Urethra, Prepuce, Testicles, and Vagina 

Atresia Urethrae. — Total atresia urethral is a rare malformation. 
When it does occur, it is usually epithelial in nature or at most mem- 
branous. In the former instance the atresia promptly yields to pres- 
sure with the tip of a sound; in the latter, to a small incision and 
dilatation by means of a small, blunt silver probe. 

Complete absence of the urethra is extraordinarily rare. 

Congenital stenoses are not rarely found along the urethra, and if 
presenting no distinct hindrance to urination are frequently over- 
looked. 

In cases of marked urethral stenosis, the still patent urachus often 
permits the escape of urine through its fistulous tract running from the 
bladder to the umbilicus. 

Misplacement of the Urethral Opening (Epispadias, Hypospadias).— 
The urethral opening may be situated on the upper part of the penis 
(epispadias) or at its inferior aspect (hypospadias). The latter ab- 
normality is more frequent than the former. Both conditions are pro- 
ductive of more or less disturbance of urination (incontinence in 
epispadias, dysuria in hypospadias), secondary intertrigo, erosion 
and ulceration of the genitalia from the effects of the irritating urine, 
and later in life interference with virility. 

Pronounced hypospadias (perineoscrotal) closely resembles hermaph- 
roditism, and, when associated with retention of the testicles, it may 
be impossible to determine the sex of the infant. 

Except in the very mildest cases early operative interference is in- 
dispensable. 

Congenital Phimosis 

A moderate degree of adherence of the prepuce to the glans penis is 
physiologic in the newborn. Ordinarily the adhesions disappear spon- 
taneously in the course of time. In some cases, however, the prepuce 
remains adherent and stenosed at its orifice so that the glans cannot 
pass through. In consequence there is more or less retention of urine 
between glans and prepuce (particularly if the latter is elongated or 
hypertrophied), infection and decomposition of the sebaceous secre- 



194 DISEASES OF CHILDREN 

tion (smegma) and secondary inflammation of the penis and adjacent 
structures. 

In the presence of inflammation urination is difficult and very pain- 
ful, the infant cries, presses and strains (in predisposed children often 
the cause of hydrocele, hernias and prolapsus recti), or, fearing pain, 
retains the urine for many hours, a habit which is apt to give rise to 
cystitis, pyelitis, and even uremic convulsions. 

Phimosis frequently forms also the cause of enuresis, priapism, mas- 
turbation, and a number of more or less reflex nervous phenomena. 

In mild cases of phimosis the prepuce should frequently be pushed 
back and forth and the retained smegma removed. When the ad- 
hesions are very firm they may be broken up with the aid of a dull 
probe and kept loose by daily retraction of the foreskin and application 
of an antiseptic cooling lotion such as lead water or a 2 per cent solu- 
tion of aluminum acetotartrate. In this manner good results are ob- 
tained within a few days. 

AVhen the preputial stenosis is the predominating trouble, slight 
nicking of the preputial ring with scissors (laterally, above, and be- 
low), followed, as before, by loosening of the adhesions, daily preputial 
retraction and local antiphlogosis, is all that will be necessary to effect 
a permanent cure. This procedure is at all times preferable to cir- 
cumcision, except in cases of phimosis associated with elongated or 
greatly hypertrophied foreskin and severe inflammation. 

Circumcision, when indicated, should be performed under very 
careful aseptic precautions, preferably under general anesthesia. The 
surgeon grasps the prepuce between the thumb and index finger, ex- 
erting sufficient traction to draw it from the glans penis, puts over it 
a shield or forceps just in front of the glans, and with scissors or 
knife removes the distal, superfluous portion of the prepuce. He next 
seizes the inner layer of the prepuce, which still covers the glans, with 
a thumb forceps and with the aid of scissors cuts it so far backward 
as to enable him fully to expose the glans and bring the edges of 
both preputial layers in apposition by a fine continuous suture. The 
dressing should consist of sterile gauze (not medicated! danger of in- 
toxication). Numerous accidents have been reported as the result 
of circumcision, but all, except uncontrollable hemorrhage in the 
hemophilic, are preventable. In such hemorrhage the actual cautery 
should be resorted to without delay and use all other therapeutic 
measures as recommended for melena (p. 230) and hemophilia (p. 553). 
Milder hemorrhages will often yield to firm compression of the penis 
with a hard catheter in the urethral canal. 



CONGENITAL MALFORMATIONS 195 

Cryptorchidism 

(Undescended Testicle) 

Normally the testicles descend into the scrotum by the end of fetal 
life. In the event of arrested development or malformation of the 
canal of Nuck, of a constriction of the inguinal ring, and malfor- 
mation of the testis, epididymis, or the vas deferens, etc., one (monor- 
chidism) or both (cryptorchidism) testicles are not infrequently re- 
tained in the abdominal cavity, at the inguinal ring, or at the upper 
portion of the scrotum. More rarely the testicles become displaced, 
and through a false passage emerge either at the crural arch (crural 
testicle; under the fold of skin between the thigh and scrotum (scro- 
tofemoral testicle) ; or behind the scrotum (perineal testicle). 

In the majority of instances an undescended testicle is free from 
any serious consequences, and reaches its normal position spontane- 
ously within the first few years of life. Occasionally, however, it may 
become impacted at the inguinal canal, giving rise to excruciating 
pain and inflammatory symptoms ; if associated with hernia, strangu- 
lation may take place in both structures at the same time; it may cause 
atrophy in the genitalia ; it may be the seat of malignant degeneration, 
and finally, it may be productive of a number of reflex phenomena 
(epilepsy?). 

Cryptorchidism should not be confounded with anorchidism or ab- 
sence from the body of both testicles (this is usually associated with 
rudimentary penis and, later, absence of spermatic secretion), or with 
ascent of the testicles from contraction of the scrotum (they descend 
with relaxation of the scrotum). 

Expectant plan of treatment is followed up to puberty in the ab- 
sence of complications. A capsular truss should be worn in cases of 
misplacement. Gentle massage is useful. Orchidopexy and other 
surgical procedures should be instituted as indications arise. Speedy 
operation in case of strangulation. 

Hydrocele 

It is a common affection of early infancy and most frequently con- 
genital in nature. Varying with the seat of the accumulation of the 
abnormal quantity of serous fluid, we distinguish the following kinds: 

1. Hydrocele Tunicce Vaginalis. — This is a unilateral, oval, smooth, 
translucent, more or less tense, fluctuating swelling, which appears first 
at the lower part of the scrotum, and gradually rises up to the abdom- 
inal ring. Posteriorly to the hydrocele usually lies the testicle. 



196 



DISEASES OF CHILDREN 



2. Hydrocele Funicili Spermatid (Hydrocele of the Cord).— This 
form resembles the former ; except that the testicle usually lies at the 
bottom of the scrotum and is distinctly separated from the hydrocele 
by a constriction. It is sometimes made up of several small cysts simulat- 
ing' a string of beads. 

3. Hydrocele Vaginalis Communicant ("Congenital Hydrocele^).— 
This form occurs when the tunica vaginalis preserves its communi- 
cation with the abdominal cavity and becomes filled with serum, form- 




Fig. 43. — Congenital hydrocele communieans. 



ing a cylindrical tumor, extending to and through the abdominal ring- 
It is often associated with hernia (hydrocele hernialis). As the con- 
tents of both are reducible on pressure the differential diagnosis be- 
tween congenital hernia and hydrocele vaginalis communieans is some- 
times difficult. In hydrocele, however, the return of fluid to the peri- 
toneal cavity occurs without intestinal gurgling — the reverse being 
the case in congenital hernia. 



CONGENITAL MALFORMATIONS 197 

Hydrocele often disappears spontaneously, especially after removal 
of reflex irritation, e. g., phimosis. If it persists, we employ local coun- 
terirritation (painting with tincture of iodine or mercury ointment), or 
aspiration, if the hydrocele enlarges. The latter procedure may be 
followed by the injection of a few drops of tincture of iodine or 
carbolic acid and alcohol. Absorption of the fluid is hastened by 
a few large doses of potassium iodide. In hydrocele communicans a 
truss should be worn to prevent hernia. The pressure exerted will often 
obliterate the inguinal portion of the vaginal process, and also cure the 
hernia, if present. 

If the aforementioned palliative and curative measures fail — which 
is rarely the case — a radical operation becomes necessary. 

Atresia Vulvae. — Atresia vulva? consists chiefly of a cellular adhe- 
sion of the labia minora, and may be partial or complete. In total atre- 
sia vulvae there is anuria, with its secondary symptoms, necessitating 
immediate attention, i. e., forcible separation of the labia with the fingers 
or with the aid of a dull probe or scalpel. In partial atresia separation 
of the labia occurs spontaneously. 

Atresia Vaginae Hymenalis (Imperforate Hymen). — This congenital 
malformation usually escapes observation until puberty, when partial 
or total retention of the menstrual flow gives rise to local and general 
disturbances. 

Incision and packing with iodoform gauze readily remedies the 
trouble. 

Atresia Vaginae. — Like the aforementioned malformation, narrowing 
or complete closure of the vagina is not detected till after puberty. 
Total atresia vagina? is usually associated with absence of the uterus. 
This should always be borne in mind before resorting to operative pro- 
cedures for the relief of the atresia. 

CONGENITAL MALFORMATIONS OF THE VERTEBRAL COLUMN 

(Including Those of the Sacrum and Coccyx) 
Spina Bifida or Hernia of the Cord 

Meningocele Spinalis, Myelocystocele, Myelomeningocele. — Analo- 
gous to hernia of the brain (see "Cephalocele"), that of the cord also is 
divisible in three principal groups : Meningocele spinalis, myelocystocele, 
and myelomeningocele. 

(a) Meningocele Spinalis. — Meningocele spinalis is a protrusion of 
the pia mater without participation of the spinal cord. It is filled with 
cerebrospinal fluid, translucent, often pedunculated and may reach the 
size of a child's head. It is covered by normal skin. Paralysis is rare. 
Pressure on the tumor produces bulging of the fontanelles and spasms. 



198 



DISEASES OF CHILDREN 



(6) Myelocystocele.— Myelocystocele is situated on a broad base and 
is readily replaceable on pressure. The covering skin is greatly distended 
but normal in color. Palpation reveals that the tumor consists of solid 
masses in addition to fluid. It is frequently associated with hydroceph- 
alus and accompanied by motor and sensory disturbances. 

(c) Myelomeningocele. — Myelomeningocele is a pear-shaped or spheri- 
cal fluctuating, tense, broad or pedunculated tumor the size of a walnut 
to that of a child's head. Its covering skin is bluish, very thin and tra- 
versed by numerous blood vessels. It is composed of cord substance 
and its membranes, and forms a true hernial protrusion through a cleft 
in the vertebral column. The cleft and to some extent also the hernial 
orifice can often be felt at the base of the tumor. Myelomeningocele is 
the most frequent variety of spina bifida and gives rise to marked motor 
and sensory paralyses. 









■ 


j .-■■;' " 


**** *ji 






*>&*"- 


~— . 


t 


,^m^ 



Fig. 44. — Myelocystocele. Note funnel-shaped eversion of the rectum owing to 
paralysis of the levator and sphincter ani. 

Almost all forms of spina bifida are associated with hypertrichosis of 
the surrounding skin. This is especially pronounced, and indeed, often 
forming the only outward sign of deformity, in spina bifida occulta (a 
meningocele usually at the sacrolumbar region hidden under masses of 
fat). The hair is usually so arranged as to form a crown over the center 
of the defect. When well developed it may resemble a tail. Apart from 
the malformation the condition of most children at first is perfectly 
normal. As the tumor enlarges the results of the pressure on the cord 
or the cauda equina gradually appear. The symptoms vary with the de- 
gree of involvement of the spinal cord; they are, therefore, most pro- 
nounced in myelomeningocele sacrolumbalis. Here we have motor and 
sensory paralyses of the legs, of the rectum, bladder, and the perineal 



CONGENITAL MALFORMATIONS 



199 



muscles, convulsions and trophic disturbances. In less severe cases, the 
paralysis may be limited to the legs only. Several years ago (Med. 
Eec, New York, Jan. 6, 1912) I called attention to persistent incon- 
tinence of urine forming- a characteristic symptom of spina bifida 
occulta. 

Bearing in mind the characteristic symptomatology of spina bifida, 
t. c, a more or less translucent, compressible, barely movable, thinly 




Fig. 4:5. — Spina bifida occulta in a boy eight years old. This condition vras associ- 
ated with incontinence of urine. 



covered tumor, in the majority of instances associated with paralyses, 
there ought to be no difficulty in differentiating it from sacrolumbar 
neoplasms. In cases of doubt the diagnosis may often be cleared up 
by exploratory puncture and radiographic examination (the latter show- 
ing a vertebral cleft). 

Spina bifida may sometimes escape notice when it is surrounded by 
a solid tumor. 

The majority of children with marked spina bifida die when very 



200 DISEASES OF CHILDREN 

young, often during birth, owing to rupture of the tumor and shock 
following rapid escape of the cerebrospinal fluid. Most of those who 
survive succumb later from rupture of the sac and subsequent infection 
and purulent meningitis; from gangrene and ulceration of the skin 
with subsequent sepsis; and finally, from intercurrent diseases and 
marasmus. Simple meningocele gives the best prognosis if recog- 
nized early and protected from external insults by a suitable pad or 
apparatus. 

This palliative method of treatment should always be tried in cases 
of spina bifida which project very slightly and are covered by nor- 
mal, well-nourished skin. Aspiration of the hernial sac is useful to 
relieve the symptoms of compression and to lessen the danger of spon- 
taneous rupture. Aspiration may be followed by injection of iodine or 
preferably iodine-gelatin. In selected cases it may prove of perma- 
nent benefit. 

A radical operation is the ideal procedure in suitable cases. How- 
ever, extensive paralyses, severe irreparable malformations elsewhere, 
hydrocephalus, and grave systemic affections are contraindications 
to operation. In such cases palliative and symptomatic methods of 
treatment are indicated. 

Congenital Sacral Tumors 

Closely related to and frequently associated with spina bifida (q.v.) 
are congenital sacrococcygeal tumors. They may be classified as follows : 

1. Double Formations — 

(a) Complete — two fully formed individuals grown together 
at the buttocks. 

(5.) Incomplete or parasitic formations — one or several rudi- 
mentary portions of the body attached to the buttocks of 
a fully formed individual. 

2. Sacral Hygromas.- — Single or multiple cysts, attached by a broad 

base to the dorsal surface of the sacrum. They are sometimes 
associated with spinal hernia. 

3. Tumores Coccygei. — Neoplasms attached to the anterior surface 

of the sacrum and coccyx. The tumors are composed of fibrous 
or granular masses generally of sarcomatous nature, sometimes 
of fat, cartilage, or bone. Occasionally they involve the spinal 
canal, or surround a spinal dural protrusion (spina bifida). 
They never extend above the lower border of the gluteus, but 
spread toward the pelvis and between the legs of the child. 

4. Caudal Formations — - 

(a) Complete tails, manifested by an actual increase in the 
number of coccygeal vertebras. 



CONGENITAL MALFORMATIONS 201 

(&) Imperfect tails, enlargement of vertebral column by rudi- 
mentary tissue. 
But few children born with coccygeal tumors live beyond the age of 
one year. As the tumors enlarge, the infants succumb to progressive 
cachexia and exhaustion. 

As a rule, sacral tumors do not interfere with the life of the child 
if suitable protection is furnished against vulnerability of the tumor 
and secondary infection. In some selected cases (see "Spina Bifida") 
perfect results are often obtained by skillful surgical measures. 

MALFORMATIONS OF THE EXTREMITIES AND HIP 

Of the numerous malformations of the extremities {e.g., complete 
absence; spontaneous partial amputations; fractures; supernumerary 
fingers and toes, etc.) but few are of interest to general practitioners — 
namely, congenital dislocation of the hip and club foot. As these ab- 
normalities are apt to be confounded with similar acquired affections, 
they will receive special consideration. 

Luxatio Coxae Cong-enita 

(Congenital Dislocation of the Hip) 

The dislocation may be unilateral or bilateral. The acetabulum is 
rudimentary in form, and the head of the femur rests either above it, 
above and to the outer side, or above and behind it upon the ilium, some- 
times immediately at the side of the great sciatic notch. If one leg is 
displaced it is shorter than the other, giving rise to distinct limping. 
If both sides are affected the gait is wobbling — ' ' duck gait. " As a result 
of this anomaly the buttocks project prominently backward while the 
spine is either thrown forward (lordosis, in bilateral) or tilted sideways 
(scoliosis, in unilateral dislocation). The differential diagnosis between 
this condition and rachitis and coxa vara is best established with the aid 
of the x-rays which show the abnormal position of the head of the fe- 
mur. If the malformation is detected early, (in a certain number of 
cases the dislocation is acquired as a result of septic arthritis in the 
newborn) it may be corrected either by opening the joint, replacement 
and fixation of the head of the femur in the artificially deepened ace- 
tabulum, or by bloodless forcible reduction of the deformity and fixation 
of the head of the femur in the acetabulum by prolonged use of plaster- 
of -Paris bandages (Lorenz's operation). For details of treatment the 
reader is referred to textbooks on orthopedic surgery. 



202 



DISEASES OF CHILDREN 



Talipes 

(Club foot) 

1. Talipes varus, inversion of the foot, so that its sole faces the other 
foot. This is the most common of the congenital forms. 

2. Talipes valgus, flat-foot, effacement of the arch. 




Fig. 46. — Bilateral club feet in father and three children. (After Joachimsthal.) 



3. Talipes equinus, lowering of the anterior part of the foot, the child 
steps on his toes. 

4. Talipes calcaneus, elevation of anterior part of the foot, heel alone 
touching the ground. 

Compound forms may be produced by combination of the different 
varieties. 

The diagnosis of the type of club foot can readily be made by inspec- 
tion; it is sometimes difficult, however, to differentiate the congenital 
from the acquired forms, e. g., rachitic or paralytic club foot. In rickets 



CONGENITAL MALFORMATIONS 



203 



the distortion of the feet is generally associated with other pathogno- 
monic symptoms of rickets and is gradual in development. In paralytic 
clnb foot (e. g., poliomyelitis) the limb is wasted, flabby and cold and 
there is a history of postnatal, gradual appearance often in association 
with other paralytic deformities. 

Congenital clnb foot is being attributed to various canses, bnt is prob- 
ably due to some mechanical interference with the normal development 
of the joints, ligaments or tendon insertions. 




Fig. 47. — Same ease as Fig. 44 showing also congenital club foot. 



Treatment of Club Foot by General Practitioner. — Oettingen re- 
marks that during the 2,000 years of experiences with club foot, the 
important part played by the knee in the correction has been almost 
entirely overlooked. The deformity develops with the knee flexed to 
the utmost, and it should be flexed at a right angle in the immobiliza- 
tion. This has the great advantage that the sole can be held in proper 
position by traction on the knee. Treatment should commence the 
moment the child is first presented to the physician, even if it is 
only one day old. Xo anesthesia is required, merely a stout twilled 
cotton flannel bandage about 4 or 5 cm. wide. The bandage is passed 
first around the foot, after the foot and thigh, just above the knee, have 
been smeared with a soft solution of mastic which glues the fuzzy 
stuff firmly to the skin. The bandage starts at the little toe and is 
wound around the foot and then passed from the little toe over the 
knee and is then brought around and across the front of the leg to the 
inner aspect of the foot, forming thus a figure-of-eight bandage. Be- 



204 DISEASES OF CHILDREN 

fore applying the bandage the physician should manipulate the foot 
to bring it with maximal outward rotation of the leg into its normal 
position, watching the clock to see that he does not take less than 
five minutes to accomplish this. During the application of the bandage 
the assistant holds the thigh with one hand and the middle toe of the 
foot with the other, not releasing it until bandaging is completed. By 
this means the sole of the foot is held in correct position supported 
by the thigh, the bandage holding the foot in pronation, outward rota- 
tion, abduction and dorsal flexion. It is impossible for the foot to slide 
back into its old position. This bandage leaves free the entire thigh, 
the under part of the knee, and the entire inward aspect of the leg 
and ankle, with a certain possibility for movement in all the joints. 
These are all immense advantages. The child is allowed to go home 
for two days, and can be bathed if the leg is held up out of the water. 
After two days the physician removes the bandage, washes the leg 
with warm water and soap, and massages the leg for a few minutes. 
A bandage is then applied, which is left for five days, and is then 
removed for an interval of four days. In the same way three more 
bandages are applied, each for a week. By the end of the fourth week 
the foot is in normal position, ready for the after-treatment. So far, 
the mother is not allowed to massage or work on the foot, but now she 
is taught to massage three or four times a day, seizing the leg above 
the malleolus, the sole toward her as she sits or stands in front of the 
reclining child. With the middle finger of the other hand on the little 
toe of the foot, she strokes the sole away from her. This one simple 
movement combines the four compensating elements for club foot, con- 
tinuing the pronation, extension, abduction, and outward rotation 
of both foot and leg. With older children a rubber strap is applied 
afterward, passing around the foot and knee like the other, with a 
buckle to keep it fast, tied with tape to keep if from slipping off the 
knee. Complicated and neglected cases of club foot, of course, require 
surgical therapeutic measures. 

CONGENITAL AFFECTIONS OF THE MUSCLES AND BONES 
Amyatonia Congenita 

(Myatonia Congenita, Oppenheim) 

Amyatonia congenita is characterized by general flaccidity of the 
muscles, especially of the lower extremities and in a slighter degree 
of the arms. The neck, cranial nerves and diaphragm are usually 
normal. Intelligence is occasionally deficient. There is no atrophy, 
but the patellar reflexes are either diminished or lost. As the af- 
fection seems to be due to delayed development of the musculature, it 



CONGENITAL MALFORMATIONS 



205 



generally improves, particularly if assisted by massage, baths and elec- 
tricity, and general tonic treatment. In a case reported by J. B. Holmes* 
postmortem examination revealed a relatively large spinal cord with the 
anterior roots diminished in size, as compared with the posterior roots. 

Myotonia Congenita 

(Thomsen's Disease) 

This is a rare, probably hereditary, affection of the muscular sys- 
tem, characterized by sudden spasm and rigidity of individual or 
groups of muscles, especially when the patient begins a voluntary 
movement, e. g., arising from a certain posture, clasping hands, etc. 




Fig. 48. — Osteogenesis Imperfecta. Every long bone of the body was repeatedly 
fractured. The child finally died at the age of two and a half years from cerebral 
hemorrhage resulting from a slight fall upon the head. (Courtesy of Dr. J. L. 
Rubinstein. ) 

Similar tonic contractions occur from the effects of a blow upon a 
muscle; and the application of a strong (20 to 25 milliamperes) gal- 
vanic current produces certain wave-like muscle contractions which 
move from the area of the cathode to that of the anode. Although 
often appearing in early infancy, the disease does not endanger life or 
health. Warm baths and massage may prove of benefit. 



Osteogenesis Imperfecta 

(Fragilitas Ossium Idiopathica) 

This rare, congenital bone affection of obscure origin is characterized 
anatomically by the unusual persistence of the interstitial cartilagi- 



■Am. Jour. Dis. Child., November, 1920. 



206 DISEASES OF CHILDREN 

nous substance and great deficiency of osseous elements and lime salts 
in the primary zone of calcification. It involves all the bones of the 
body. They are soft and thin and readily bend and break on the slight- 
est manipulation ; hence the frequency of several fractures during de- 
livery of the baby. Those who survive early infancy, often succumb 
to fractures of the head, spine or ribs when they begin to stand or 
walk. Cases reaching adolescence, however, are on record. As frac- 
tures of the long bones are not rarely met with in congenital syphilis, 
osteogenesis imperfecta is apt to be mistaken for the former disease. 
In syphilis, however, we have several other characteristic signs, in- 
cluding positive Wassermann reaction, which are absent in osteogene- 
sis imperfecta. For its differentiation from rachitis, see p. 511. 

Treatment. — Avoidance of traumatism and attention to the general 
health of the baby. Phosphorus preparations and cod liver oil may be 
tried, especially in mild cases. As the thymus is not rarely found at- 
rophied, thymus treatment is worth trying. 

Achondroplasia (see p. 512). 



CHAPTER IV 
INJURIES AND DISEASES OF THE NEWBORN 

I. BIRTH INJURIES 

Nature in its infinite wisdom provides a more or less large quantity 
of liquor amnii to protect the fetus in utero against undue pressure 
and possible injury. If, perchance, the amniotic fluid escapes prema- 
turely, either spontaneously or artificially, the fetus, in its descent 
through the parturient canal, subjected to powerful pressure by the 
maternal structures or mechanical manipulations, sustains a number 
of injuries which vary in severity from simple external bruising to 
grave compound fractures and internal, sometimes fatal, injuries. 

A. Superficial Structures 

Caput Succedaneum 

Vertex presentation being the most common form of delivery, the 
head consequently stands the brunt of the injuries. The so-called 
caput succedaneum is a circumscribed edema of the scalp and consists 
of a serous or hemorrhagic extravasation into the subcutaneous tis- 
sues of the scalp. It is observed immediately after birth as a doughy, 
evenly distributed, variously sized, soft tumor which disappears spon- 
taneously by absorption, unless infected through external abrasions. 
In the latter event it requires surgical treatment, such as antiseptic 
dressings, incision and drainage. 

Cephalhematoma 

More serious than the aforementioned condition is hemorrhage oc- 
curring between the pericranium and cranial bones in the form of a cir- 
cumscribed, elastic, distinctly fluctuating, painless tumor, situated 
upon the right or left side of the head (sometimes both sides are af- 
fected). The cephalhematoma develops gradually within the first few 
days of extrauterine life, and owing to the firm attachment of the 
periosteum to the edges of the cranial bones along the sutures, it never 
extends beyond the latter or over the fontanelle. All around the tu- 
mor a hard, bony ridge is soon (after about two weeks) detected, 
which with the depressed center gives a sensation somewhat like that of 
a depressed fracture. 

207 



208 DISEASES OF CHILDREN 

Cephalhematoma may be mistaken for caput succedaneum, which 
appears immediately postpartum and disappears after a day or two ; 
for subaponeurotic or subcutaneous hemorrhages, which occur some- 
times also from intrapartum pressure, but extend beyond the sutures; 
for congenital encephalocele, which lies between but not over the 
bones, pulsates, enlarges on crying or coughing, and can be partially 
reduced; and, finally, for vascular tumors, which are compressible and 
free from a bony ridge. 

The tumor usually disappears spontaneously, sometimes requiring 
weeks and months to do so. If suppuration occurs, it calls for surgical 
interference. 

Hematoma Sternocleidomastoidei 

Pathologically akin to cephalhematoma is the intrapartum hemor- 
rhage which takes place within the sheath of the sternocleidomastoid 
muscle, as a result of rupture of several muscle fibers and consecutive 
myositis. 

The tumor in the neck is generally observed a few weeks after birth, 
more rarely earlier, by noting the baby holding its head on the side. 
It varies in size from that of a hickory nut to a walnut. It is at first 
soft, later hard and cartilaginous in consistence. Severe hemorrhages 
may give rise to torticollis. 

This condition demands perfect rest to the head, cold compresses 
for the relief of pain, and later gentle massage to promote absorption 
of the tumor. 

3* 

ITng. kalii iocl. (U. S. P.) I . 

Adipis lanae aa 3 ii 8.0 

M. ft. ITng. I 

S. : To be applied with gentle massage once a day. 

2. Deep Structures 

Birth traumatism is not always limited to the skin and muscles. 
Now and then the viscera (the lungs, liver, peritoneum, etc.), the bones, 
the peripheral nerves, the meninges and brain are involved. Fractures 
and dislocations are not rarely observed, especially in the long tubular 
bones and the clavicle, while the cranial bones are often badly dis- 
placed (the occipital and frontal are pushed under the parietals), fis- 
sured (see "Meningocele,"), compressed and fractured, giving rise to 
grave, frequently fatal, intracranial hemorrhages. 

Central Birth Paralysis 
Cerebral Hemorrhage Apoplexia Neonatorum 

Usually the seat of the hemorrhage is the subarachnoid space ; often 
the delicate pia mater; sometimes between the dura and arachnoid; 



INJURIES AND DISEASES OF THE NEWBORN 



209 



more rarely between the meninges of the cerebellum; the lateral ven- 
tricles, and exceptionally the brain substance. 

According to Seitz the hemorrhage is the result of rupture of the 
longitudinal sinus or veins, of the transverse sinus or of vessels of the 
chorioid plexus. 




Fig. 49. — Method of insertion of trocar through the anterior fontanel to reach the 
ventricles. (After P. Kavaut.) 



The symptoms differ with the extent and seat of the hemorrhage. 
For several hours no characteristic symptoms may be evident. How- 
ever, most infants are born asphyxiated. The majority of those born 
alive succumb within a few days under symptoms of asphyxia and ate- 



210 



DISEASES OF CHILDREN 



lectasis, slow, full, irregular pulse, frequently high fever, nystagmus, 
bulging of the fontanelles, sopor, convulsions, rigidity and paralysis. 
Those few who survive, often at an early age or later present the 
symptom-complex of cerebral paralysis (see p. 601) with or without 
idiocy. 

The treatment is essentially the same as in traumatic cerebral hemor- 
rhage in older children — principally surgical. (See p. 604.) An at- 
tempt may be made to relieve the intracranial pressure by lumbar 
puncture or aspiration of the subdural space. Lumbar puncture is al- 
ways worth trying, and if it brings blood, which is often the case 
in infratentorial hemorrhage, the puncture should be repeated two or 
three times,* each time withdrawing from 5 c.c. to 15 c.c. Aspiration 
of the subdural space is accomplished by introducing a trocar almost 
parallel with the surface of the skull, at a point corresponding with 
the lateral angle of the anterior fontanelle, and withdrawing a suffi- 
cient amount of blood to relieve the pressure symptoms (Fig. 49). 

F. C. Roddaf suggests the subcutaneous injection of 25 c.c. of blood, 
if the patient's blood is found wanting in coagulability. 

Peripheral Birth Paralysis 
Facial Palsy- 
Facial paralysis in the newborn is usually of traumatic origin as a 
result of pressure exerted upon the facial nerve by the obstetrical 




Fig. 50. — Obstetric facial paralysis in boy fifteen months old, which failed to yield 

to treatment. 



forceps or deformed pelvis. It may be unilateral or bilateral. It 
resembles facial paralysis of older children (see p. 663) except that it 



*H. Vignes, Progres Med., No. 33, 1918, J. M. Brady, Jour. Am. Med. Assn., Sept. 21, 1918. 
fjour. Am. Med. Assn., Aug. 14, 1920. 



INJURIES AND DISEASES OF THE NEWBORN 



211 



runs a milder course. Very rarely the paralysis is permanent. It is 
important to differentiate this form of facial paralysis from that of 
central origin. In the latter form, as a rule, other portions of the 
body are involved, while the orbicularis palpebrarum remains free. 
The so-called congenital, nontraumatic facial paralysis is probably 
syphilitic in nature. 

Brachial Paralysis— Obstetrical Paralysis— Duchenne-Erb Paralysis 

In mild form it is of quite frequent occurrence. In typical cases 
the paralysis is usually limited (80 per cent) to the muscles supplied 



/ ^^^IKa \ 


A^ * 


1 } 



Fig. 51. — Bilateral obstetric brachial paralysis, the so-called ' ' Dnehenne-Erb 

Paralysis ' \ 

by the brachial plexus composed of the lower four cervical nerves 
and the first dorsal, and their branches, i. e., the deltoid, biceps, brach- 
ialis anticus, infraspinatus, supinator longus and the supinator brevis. 
The arm (rarely both sides are affected — from reckless instrumental 
manipulations) hangs motionless, the upper arm is rotated inward, 



212 



DISEASES OF CHILDREN 



the forearm is pronated, and the palm of the hand is turned backward 
and outward (Fig. 51). The wrist and finger-joints are usually only 
slightly affected; sensibility is intact and electrical reaction diminished 
or lost. 

Recovery is the rule in mild cases. Those lasting over three months 
show trophic changes in the affected muscles, especially in the deltoid. 
The prognosis in cases of brachial paralysis presenting reaction of de- 
feneration, is doubtful. 




Fig. 52. — Obstetric brachial palsy: Erb 's "upper arm type''; failed to respond to 

treatment. 



Treatment. — After keeping the affected arm perfectly at rest for two 
weeks, the faradic or galvanic current should then be applied daily, 
for about five minutes at a time, until muscular power has been re- 
stored. Gentle massage and passive motion are very useful as a proph- 
ylactic against atrophy and contractures. In complete rupture of 
one or more cords of the brachial plexus, nerve end-to-end anastomo- 
sis and tendon transplantation are the only curative means at our 
command. Muscle training is indicated in children old enough to 
respond to suggestions. 



INJURIES AND DISEASES OF THE NEWBORN 213 

II. DISEASES OF THE NEWBORN 

Feeble Vitality of the Newborn 

The physician is often confronted by a group of clinical phenomena 
in the newborn which ma}^ briefly be designated as "feeble vitality." 
It is a clinical entity which, though greatly at variance as to cause and 
ultimate course, presents at birth a uniform symptom-complex and de- 
mands a more or less uniform mode of treatment. 

It is characterized by pronounced respiratory and circulatory dis- 
turbances, subnormal temperature, somnolence, general debility with 
or without emaciation, and is usually associated with one or several 
presently to be described diseased conditions. 

1. Asphyxia Neonatorum 

( Suspended Animation ) 

The asphyxia may be momentary, or last several minutes up to 
an hour or longer. Mild forms of asphyxia are manifested by slight 
lividity (asphyxia livida) of the face, feeble superficial breathing, and 
slow and weak heart beat. If the asphyxia is allowed to continue, 
the face becomes deeply cyanosed and congested, the eyes bulge, 
the muscular tonus and cutaneous sensibility are retarded, the umbili- 
cal cord is collapsed, and respiration is barely perceptible. Finally, 
the infant becomes deathly pale (asphyxia pallida), the muscular 
tonus and reflexes are lost, the heart beat is scarcely audible and res- 
piration ceases. 

Postmortem examination reveals overdistention of the right ventri- 
cle of the heart; cerebral, pulmonary and hepatic congestion; in- 
creased fluidity of the blood; serosanguinolent exudation in the serous 
cavities; accumulation of liquor amnii, blood and mucus in the air pas- 
sages, and pulmonary atelectasis. 

Prompt and prolonged resuscitating efforts (Sylvester's, Schultze's 
and Laborde's) are usually attended by favorable results. HoAvever, 
intracranial hemorrhage with consecutive mental and physical defects 
are not infrequent sequela? of severe forms of asphyxia. 

2. Atelectasis Neonatorum 

(Congenital Collapse of the Lungs) 

Inflation of the lungs of the normal newborn begins with its first 
cry uttered announcing its arrival into the domain of the living. Suc- 
ceeding respiratory acts gradually unfold the originally collapsed al- 
veoli and bronchioles, and full expansion of the lungs is ordinarily 



214 DISEASES OF CHILDREN 

completed within the first forty-eight hours. The posterior portions 
of the lower lobes, particularly the right, are last to expand. 

Failure of the lungs fully to unfold gives rise to the condition under 
discussion, i. e., atelectasis pulmonum. 

Most alveoli and bronchioles are collapsed. The lung is brownish red 
in color, feels tough and resistant to the touch — like liver — does not 
crepitate, and sinks in water. Usually both lungs, particularly the poste- 
rior parts of the lower lobes, are affected. In cases succumbing to the 
disease after weeks or months there is also found congestion of the 
heart, spleen and liver. 

The causes of atelectasis are essentially the same as those of asphyxia ; 
the former is sometimes a sequel of the latter, especially if inadequately 
treated. Inflation of the lungs is occasionally interfered with by congen- 
ital hyperplasia of the thyroid or thymus glands compressing the trachea. 

In marked atelectasis the infant makes but faint efforts to respire. 
It is pale, sometimes cyanotic ; its temperature is subnormal and its 
pulse slow and weak. It is unable to suckle properly and to cry aloud. 
It sleeps most of the time and but lazily responds to external influence. 
Auscultation discloses weak and vesicular breathing (never bronchial) 
and occasional crepitation. Slight dullness on percussion. The diagnosis 
may often be verified by a radiogram. 

A great number of otherwise healthy children recover under prompt 
and energetic treatment. Delicate infants either die a few hours, days 
or several weeks after birth from prostration following repeated at- 
tacks of cyanosis, or survive and remain debile for life, often suffering 
from organic defects, such as incomplete closure of the foramen ovale or 
ductus arteriosus, and the like. 

The treatment of atelectasis consists in stimulating the respiratory 
and circulatory functions by keeping the infant wide awake at intervals ; 
frequent change of position ; artificial respiration ; alternating warm and 
cold baths or showers followed by brisk friction ; oxygen inhalation, and 
gentle faradization. In all other respects they should be treated like 
premature babies. 

3. Vitia Cordis 

(See p. 525) 

4. Syphilis Embryonalis S. Fetalis 

(See p. 482) 

5. Premature Birth 

Children born before full term — between the twenty-eighth and 
thirty-eighth weeks of intrauterine life — are designated "premature." 



INJURIES AND DISEASES OF THE NEWBORN 215 

Thanks to the earlier and better recognition of syphilis, the more 
thorough appreciation of the methods of its prevention and cure, as 
well as the tendency of the syphilitic virus spontaneously to lose its 
virulence through attenuation, premature births, being due chiefly to 
parental syphilis, are no longer as frequent in occurrence as in former 
years. 

The physical condition of premature infants rests largely upon the 
period of prematurity, inherent vigor of the newborn, and the pres- 
ence or absence of serious organic defects. Ordinarily premature in- 
fants are considerably punier than full term infants. They weigh and 
measure approximately — 

WEIGHT SIZE 

At 29 weeks 1600 Gm. 314 lb. 40 Cm. 15 inches 

" 31 " 1900 " 4 " 13 " 16 14 inches 

"33 " 2100 " 414" 44 " 16% indies 

"35 " 2600 " 5% " 47 " 17% inches 

" 37 " 2800 " 5% " 48 " 18 inches 

"40 " (full term) 3100 " 614" 52" 19% inches 

The body is limp ; the movements of the extremities are helpless and 
tardy. The face is usually sunken and senile. The skin is soft and 
delicate, vulnerable to an extreme, hence readily susceptible to in- 
fectious processes. Respiration is irregular, superficial and sometimes 
of the Cheyne-Stokes type. Atelectasis and cyanosis are not rare ac- 
companiments. The heart beat and pulse are weak, often irregular, 
and the blood lacks in coagulating power. The bones are soft, more 
or less yielding to light manipulation. The temperature is subnormal. 
Premature infants, as a rule, are unable to suckle or swallow properly 
and, owing to incapacity of the digestive organs and atony of the 
intestinal musculature, fully to assimilate the food consumed. Severe 
colic and uric acid infarcts, which latter often lead to anuria and other 
uremic manifestations, add misery to their painful existence. 

Encumbered with so many deficiencies, the span of life of the delicate 
premature infant must obviously measure but a few hours or days. 
The mortality of premature infants under 1,600 grams in weight, es- 
pecially if they are inadequately cared for, is estimated to be about 
80 per cent ; of those weighing over 2.000 grams, 40 per cent ; while 
of those weighing over 2,500 grams only 20 per cent — almost as low 
as with full-term babies. Such as survive, however, often remain very fee- 
ble for many years, manifest a greater tendency to disease, and lack 
power of resistance to overcome it. Occasionally, after many ups and 
downs, premature infants marvelously extricate themselves from the 
pangs of death and grow up full of vivacity and vigor. I have now 



216 



DISEASES OF CHILDREN 



under observation a premature baby ten months old, weighing 12 lbs. 
that at birth weighed only 2*4 lbs. For the first six weeks it was fed 
on breast milk by means of a catheter through the nose. 

It is therefore incumbent upon the physician to look upon every 
premature infant that respires at birth as one whose life can be pre- 
served by suitable care and treatment. 

Management of " Feeble Vitality of the Newborn" With Special Ref- 
erence to the Premature Baby 

Three special indications are to be met in the management of the 
newborn, who are delicate. We must (1) endeavor to maintain the 




Fig. 53. — Incubator room for newly born babies with feeble vitality. (After Tli. 

Eseherich.) 

best features of antenatal life; (2) supply nutriment suitable for the 
infant's growth and development: and (3) awaken and strengthen the 
dormant or inefficient functions of its organs. 

The first prerequisite should be met by an artificial environment 
which should as nearly as possible resemble that of the interior of 
the uterus. In very delicate and puny babies the numerous modern 
incubators on the market, in many instances, answer the purpose. 

The temperature of the incubator is maintained steadily at about 
96° F., and fresh air supplied by the automatic ventilating contrivance 
and by, off and on, leaving the door open. Infants showing a fair 
amount of vitality usually get along very well without incubators, 



INJURIES AXD DISEASES OF THE NEWBORN 



217 



the latter being supplanted by ordinary bassenets and warm-water 
bags, or preferably the modern electric pads. The infant is clothed 
in a woolen shirt and napkin and placed in the incubator or is wrapped 
in a "premature gown" which consists of a layer of absorbent cotton 
between two layers of gauze. A hood of the same material is attached 
to the body of the gown. The temperature of the baby's room should 
range between 74 to 78° F., or higher if the baby's temperature con- 
tinues subnormal. 

Delicate incubator babies should be disturbed as little as possible, 
and removed only for feeding and cleansing (by means of lukewarm 
oil) or for such therapeutic purposes {e.g., artificial respiration, as ne- 
cessity arises). Bathing is contraindicated, and any undue handling 
of the skin or mucous membranes must be carefully avoided, since most 
trifling injuries are very apt to be followed by fatal sepsis. 

Every effort should be made to feed the premature infant on woman's 
milk for at least the first feAv weeks of extrauterine life. AYhen too 
weak to suckle from the breast, the milk may be given every three 




Fig. 54. — Breck's feeder 

hours by means of a dropper or Breck's feeder, care being taken that 
the milk flows down into the throat very slowly, lest it enter the trachea 
and lead to aspiration pneumonia. In the absence of breast milk, 
light mixtures of cow's milk (% per cent of fat, % per cent protein, 
and 6 per cent of milk sugar) should be administered every two to 
three hours in quantities of 4 to 8 teaspoonfuls. The amount is grad- 
ually to be increased. If the baby is unable to swallow, the milk may 
be administered by garage, or by catheter through the nose. 

The third indication applies principally to infants who, though born 
at full term, possess very little vitality, and whose organs, especially 
the heart and lungs, fail to functionate. The vitality is best aroused 
by artificial respiration — by alternate flexion and extension of the 
infant's body while it lies upon the operator's palms. An occasional 
dash of cold water upon its face, to induce the child to cry aloud and 
to take deep breaths, and stimulation by means of oxygen, caffeine 
and digitalis serve as useful adjuvants. 



218 DISEASES OF CHILDREN 

Sclerema Neonatorum 

(Sclerema Adiposum) 

This very rare affection may be primary, without any apparent 
cause, or secondary in nature as a result of great loss of body fluids 
(internal hemorrhages, gastrointestinal disease) or extensive exuda- 
tions into internal cavities (thorax). It occurs principally in the pre- 
mature, very feeble and badly nourished infants in the first few days 
of life, but also very much later, up to six months of age. 

It begins in the lower extremities, particularly the calves. From 
here it spreads symmetrically over the thighs, loins, trunk, neck, upper 
extremities and head, leaving penis, scrotum, planta pedis, and palma 
manus uninvolved. The skin is dirty yellow, very tense, cold, hard, 
immovable over the underlying structures, and does not pit on pres- 
sure. 

From day to day the skin becomes more indurated, marbleized, 
and the patient lies stiff with rigid, mask-like face and firmly closed 
mouth as though in a state of tetanus. Sucking is often impossible. 
There is gradual sinking of all vital functions. The temperature falls 
(to 85° F., or lower), the heart action becomes weak, the pulse is 
slow and barely perceptible, respiration shallow and irregular, the 
voice feeble and whining, the intestines and kidneys are inactive, the 
child wastes rapidly and death ensues in about a week from exhaustion 
or from some complication, the commonest being pneumonia and sepsis. 
Milder cases, especially older infants, not infrequently recover.. 

Treatment. — Early hypcdermo- and entero-clysis with hot (104° to 
106° F.), normal saline solution (from 2 to 3 ounces t. i. d.) ; gentle 
massage with oil ; stimulation ; maintenance of body heat ; careful feed- 
ing, etc., as outlined under "Feeble Vitality of the Newborn." (See p. 
216.) 

Scleredema Neonatorum 

(Sclerema Serosum) 

This form of edema affects especially premature, weak (twins), ate- 
lectatic and syphilitic infants. It usually begins a few days postpartum 
(it is rarely congenital) with puffiness and swelling of the feet and legs. 
The edema soon extends upward (involving also the mons veneris, 
scrotum and penis) over the entire body except the chest, and rarely 
the eyelids and face. The skin is tense, shiny, waxy white, or cyanotic, 
and pits on pressure. "When the edema increases it greatly resembles 
true sclerema, but may be differentiated from the latter by bearing 
in mind the following characteristic symptoms: 



INJURIES AND DISEASES OF THE NEWBORN 219 

SCLEREMA SCLEREDEMA 

Color of skin Dirty yellow. Shiny or mottled. 

Parts exempt Genitals, palms of the Chest. 

hands and soles of the 

feet. 
Pitting on pressure Absent. Marked. 

The general symptoms, such as low temperature, great depression, 
etc., are not quite as pronounced as in sclerema adiposum. 

The prognosis is not as grave as in true sclerema. 

The treatment consists chiefly of stimulation (camphor, digitalis) 
hot baths, massage and passive motion, active diuresis and proper 
feeding. (See also "Feeble Vitality of the Newborn," p. 216.) 

Sepsis Neonatorum 

With the usual aseptic precautions that are now being taken in the 
management of labor and the puerperium, the number of cases of sep- 
sis neonatorum has been reduced to a minimum. This is true espe- 
cially of systemic sepsis. The extreme importance, however, of the 
subject in question, demands its careful consideration. 

LOCAL SEPSIS 

Omphalitis (Inflammation of the Navel) 

Simple omphalitis is manifested by delayed closure of the umbilical 
wound after separation of the umbilical cord, wetness, slight suppura- 
tion, and incrustation. There is no inflammatory reaction in the sur- 
rounding parts. The general health is undisturbed. 

Phlegmonous omphalitis usually begins the second week after birth. 
The navel forms an ulcerated conical projection. The surrounding tis- 
sue is firm, infiltrated, glossy and painful to the touch. Sometimes the 
inflammation extends rapidly; over the abdominal wall or into the 
deeper structures, giving rise to peritonitis. In one case under obser- 
vation, secondary suppurative foci developed in the lower portion of 
the gladiolus sterni (leaving behind an open fistula) and in the left 
hip-joint, completely destroying the caput femoris and giving rise to 
a permanent dislocation (Fig. 55). The constitutional symptoms vary 
with the degree of the severity of the affection, but are sufficiently 
pronounced to make the child quite ill and to render the prognosis 
doubtful. Milder cases may terminate in suppuration, but with careful 
treatment (see p. 221) end in recovery. 



220 



DISEASES OF CHILDREN 




Fig. 55. — Absorption of left head of femur and consequent dislocation of the 
hip in a child two years old as a direct result of sepsis neonatorum which began with 
an infection in the navel. 



INJURIES AND DISEASES OF THE NEWBORN 221 

Erysipelatoid omphalitis is a very grave affection, often terminating 
fatally either within a few days from exhaustion or a week to ten days 
later from septic peritonitis, icterus, and local suppuration. The symp- 
toms and treatment are the same as in ordinary erysipelas. 

Diphtheritic omphalitis (ulcus umbilici) is characterized by a fibri- 
nous umbilical exudation which, when cast off, leaves behind a super- 
ficial or deep ulcer. Occasionally it is due to the Klebs-Loffler bacillus. 

Gangrenous omphalitis ends fatally in the majority of cases. At first 
a small, discolored, ulcerated spot, if not immediately arrested, it 
rapidly develops into a large, gangrenous, fetid mass. It sometimes 
extends into the deeper structures, giving rise to peritonitis, urinary 
and fecal fistula?, profuse hemorrhage and pronounced constitutional 
symptoms. 

Treatment. — As the umbilical wound forms the principal and most 
frequent portal of entry for septic infection, the importance of caring 
for the umbilicus with the minutest detail is quite obvious. Strictest 
cleanliness should be enforced and unnecessary handling prohibited. 
Clean scissors, clean ligature, preferably composed of several strands of 
cotton or silk thread, and, above all, clean hands should be used in cut- 
ting, ligating and dressing the cord. The dressing should consist of a 
few layers of sterile linen cloths and dusting powder (1 part of salicylic 
acid and 6 parts of starch) and be changed every alternate day, preceded 
by cleansing the wound with a little pure alcohol to hasten desiccation 
of the umbilical rest. As moisture favors the growth and absorption 
of the bacteria which accumulate at the naval wound, the child should 
receive daily a sponge bath instead of a tub bath, until the navel has 
completely cicatrized. 

To prevent hernia as well as access of dirt, the umbilical band should 
be continued for a few weeks after complete healing of the navel. 

If inflammation of the navel, no matter how slight in degree, occurs 
notwithstanding all the precautions, it should receive immediate and 
energetic treatment. Procrastination is dangerous, nay, often fatal. 

Cauterization of the affected parts with a 2 per cent to 5 per cent so- 
lution of nitrate of silver, once a day or less often, is very useful in 
all forms of omphalitis. The wound should be kept scrupulously clean, 
and protected by a moist (boric acid, 4 per cent solution) gauze dress- 
ing, covered by rubber tissue. If the septic process does not yield 
to this treatment early, a surgeon should be consulted. A bacterio- 
logic examination may prove helpful in giving a correct clue as to 
the treatment, as for example, in diphtheritic omphalitis, where diph- 
theria antitoxin is of undoubted benefit. (See "Biologic Therapeu- 
tics," pp. 75 and 82.) 



222 DISEASES OF CHILDREN 

Omphalorrhagia (Bleeding from the Navel — Idiopathic Umbilical 

Hemorrhage) 

Umbilical hemorrhage may occur as a result of tearing the cord dur- 
ing delivery, defective ligation, or imperfect establishment of respira- 
tion (delaying the closure of the umbilical vessels). The hemorrhage 
may be slight or severe, but is readily controllable. In contradistinc- 
tion to these forms of navel bleeding which take place soon after birth, 
there is another variety of bleeding from the navel, the so-called 
idiopathic or spontaneous umbilical hemorrhage which occurs at about 
the time the umbilical rest separates (between the fourth and ninth 
daj's). The bleeding takes the form of a steady oozing of blood as 
though coming from a compressed wet sponge. It is probably due to 
sepsis of the umbilical blood vessels. Some authors are inclined to at- 
tribute it to congenital syphilis or transitory hemophilia. (See p. 229.) 
In a great many instances the hemorrhage cannot be arrested, death 
taking place either from exsanguination or from gradual exhaustion 
and complications (sepsis). 

For details of treatment see "Melena." 

Umbilical Granuloma (Excrescence, Fungus, Sarcomphalos) 

It is a strawberry-like, small tumor, attached to a broad base or 
pedicle at the umbilical stump. It bleeds readily and usually dis- 
charges thin pus. Like exuberant granulations in other localities, it is 
promptly cured by a few applications of nitrate of silver (the stick, 
or 10 per cent solution). It should not be confounded with " Per- 
sistent Omphalomesentericus. ' ' 

Ophthalmoblennorrhea Neonatorum (Gonorrheal or Purulent 

Ophthalmia) 

Gonorrheal ophthalmia is caused by infection of the conjunctiva 
of one or both eyes by the Neisser gonococcus. The inoculation usu- 
ally occurs during the passage of the head through the parturient canal 
containing a gonorrheal discharge. It may also be conveyed to the 
eyes of the infant postpartum by means of the ringers of the attendant 
or articles in use which have been soiled by the purulent discharge. 

The disease begins two or three days after the gonorrheal inocula- 
tion, with intense tumefaction of the lids, redness, swelling and thick- 
ening of the conjunctivae, lacrimation, and mucous and mucopurulent 
secretion. From day to day the discharge becomes thicker and more 
purulent; the conjunctiva assumes a velvet-like appearance (chemo- 



INJURIES AND DISEASES OF THE NEWBORN 



223 



sis), and papillary deposits or longitudinal folds appear upon the con- 
junctiva bulbi. If not immediately arrested, especially if the purulent 
secretion is allowed to accumulate between the edematous, pasted 
lids, the disease spreads rapidly to the cornea causing haziness, mac- 
eration and partial or total perforation. As a result of the latter 
and depending upon its location, total or j>artial staphyloma, panoph- 
thalmitis, with phthisis bulbi, capsular cataract, and anterior synechias 
may supervene. 

Occasionally, particularly in delicate infants, gonorrheal conjunc- 
tivitis gives rise to numerous complications, such as articular affec- 
tions, gonorrheal rhinitis, stomatitis, etc. 

The duration of the disease varies from four to eight weeks. 

Until the introduction of Crede's method of prophylaxis, gonorrheal 
ophthalmia was supposed to have contributed 60 per cent of the cases 
of blindness of one or both eyes. At present the percentage has been 
reduced to one-third, and with early and careful treatment the prog- 
nosis is still more favorable. 



Proportion of Pupils Newly Admitted to New York Schools for the Blind 

During the Past Ten Years Who Are Blind Prom 

Ophthalmia Neonatorum 



School 
Year 


No. of 
public schools 


Total new 
admissions 


Blind 
from O. N. 


Per cent 


1907-08 


10 
14 
13 
15 
24 
21 
19 
28 
35 
34 


290 
300 
32'5 
351 
415 
386 
428 
602 
66Q 
647 


77 
68 
67 
81 
88 
88 
84 
91 
127 
119 


26.5 


1908-09 


22.6 


1909-10 

1910-11 


20.6 
23.9 


1911-12 

1912-13 


21.2 
22 7 


1913-14 


19.6 


1914-15 

1915-16 

1916-17 


15.1 
19.0 
18.4 



Gonorrheal ophthalmia is not to be confounded with simple con- 
junctivitis not infrequently met in the newborn in connection with local 
sepsis. The latter variety is readily recognized by the absence of gon- 
ococci in the discharge and by its much milder course. 

Treatment. — Where there is the least suspicion of gonorrhea in the 
mother, her parturient canal and external genitalia should be carefully 
disinfected by a bichlorid solution (1 to 5000) before, during, and after 
delivery. In addition to this, the following directions in the way of 
prophylaxis (Crede's method) should be promptly resorted to: Wash 
off each eye with a boric acid wipe ; into each eye instill two drops of a 2 



224 DISEASES OF CHILDREN 

per cent solution of silver nitrate ; in about thirty seconds wash out the 
excess with saline solution. This should he done as early after birth as 
possible. During the puerperal state the child should be kept away 
from the mother. 

If only one eye be affected the fellow eye should be securely covered 
by a watch-glass or a small pad of lint, oiled silk and roller bandage. 
This protected eye should be inspected and cleansed twice daily. 

As soon as the child is seen by the physician, he should pencil the 
affected eye with a 2 per cent silver solution. If this occurs early, the 
ophthalmia may sometimes be arrested in its incipiency or at least 
rendered milder in its course. 

The affected eye must be handled by the nurse from behind the pa- 
tient's head. Small, round layers of lint are transferred, every three 
to five minutes from a large square of ice to the affected eye, con- 
tinuously for one hour. An intermission of one hour is then given 
and the cold applications are resumed. This should be continued day 
and night until there is positive evidence of abatement of the inflam- 
mation and excretion. This usually occurs within two weeks. The 
eyes should be carefully but very gently cleansed every half hour with 
warm, saturated solution of boric acid (4 per cent). If the lids are so 
swollen as not to permit thorough cleansing, canthotomy may have to 
be resorted to. Silver being the most proficient antigonococcus, a 
2 to 3' per cent solution should be applied to the conjunctiva daily so 
long as the excretion is profuse and less often when it becomes more 
scanty and less purulent. Instead of nitrate of silver we may employ 
argyrol, silvol, solargentum, or protargol in from 5 per cent to 10 per 
cent solutions. In involvement of the cornea the ice cloths should be 
discontinued, and warm applications used instead. A 1 per cent 
solution of atropine should be used as necessity arises. In bad cases 
antigonococcus vaccine is worth trying. 

Examination of the discharge for gonococci should be made at least 
once a week, and the case should not be regarded noncontagious and 
out of danger until the discharge from the eye remains free from 
gonococci for at least two weeks. The treatment of gonorrheal oph- 
thalmia should not be intrusted to unskillful hands. The better trained 
the nurse is in handling serious eye cases, the more rapid and perfect 
the recovery. 

Pemphigus Neonatorum 

Simple, nonsyphilitic pemphigus (see p. 484) makes its appearance 
between the fifth and twentieth day of the child's life. It is quite 
communicable, sometimes epidemic, and is probably due to the staphy- 



INJURIES AND DISEASES OF THE NEWBORN 225 

lococcus pyogenes aureus. Its seat of predilection is the abdomen and 
inguinal region, but the lesion may be found on any part of the body. 
It but very rarely affects the palms of the hands and the soles of 
the feet, herein markedly differing from syphilitic pemphigus. The 
eruption consists of tense bullae, varying in size from a lentil to a 
quarter of a dollar piece and contains a serous, rarely seropurulent fluid. 
The blebs are situated upon a reddened base, and on bursting leave 
moist, red spots which very soon are covered over by skin. Occa- 
sionally ulceration of the skin supervenes, and is accompanied by high 
fever and other constitutional symptoms (malignant pemphigus). 
This severe form of the disease is observed particularly in cachectic 
and bottle-fed infants exposed to insanitary surroundings, and often 
leads to a fatal issue. In otherwise healthy, well-nourished and well- 
kept infants, recovery may be expected within from two to three 
weeks. 

Simple pemphigus is preventable by strict attention to general hy- 
giene and proper feeding. Those in charge of the child should be 
cautioned as to the communicability of the disease. If large surfaces 
are involved, warm baths are very useful, preferably with boric acid (2 
per cent), solutions. They may be administered two or three times a 
day and followed by dusting over the moist surface with — 

fy Bismuthi subgall., 

Acidi salicyl aa gr. x. i 0.6 

Zinci stearat Si | 30.0 

and enveloping the body in cotton. Occasionally, applications of a 
2 per cent solution of nitrate of silver. Autogenous vaccine in malig- 
nant cases. 

Dermatitis Exfoliativa Neonatorum 

Slight dermatitis, or erythema, with or without desquamation, is 
more or less physiologic in the newborn. There is, however, an ob- 
scure (sepsis?) form of exfoliative dermatitis which is peculiar to early 
infancy (usually in the second, rarely after the fifth week of life), 
and is closely related to pemphigus. It begins with inflammation of 
the oral mucous membrane, rhagades at the angles of the mouth, and dif- 
fuse redness of the entire body, followed by active desquamation of the 
skin in large lamellae. It is sometimes preceded by detachment of 
skin and bursting of vesicles filled with clear fluid. Not infrequently 
the erosions extend to the oral mucous membrane. 

The disease runs its (afebrile) course in a few weeks, and in robust 
children ends favorably. In delicate children it may be followed by 



226 DISEASES OF CHILDREN 

general furunculosis or even gangrene, gastrointestinal disturbances 
and pneumonia, and prove fatal. 

Like nonsyphilitic pemphigus, dermatitis exfoliativa is preventable by 
scrupulous cleanliness, and the avoidance of local irritation. The 
local treatment consists of inunctions of 1 per cent salicylic or carbolic 
acid oil. 

GENERAL SEPSIS 

In speaking of primarily local septic affections, attention has been 
directed to the frequency with which grave constitutional symptoms 
are observed during their protracted course. In these cases the sys- 
temic manifestations are secondary to the local ones, and if the latter 
are detected and treated early, the former may be prevented or ar- 
rested in their incipiency. We are now about to describe a group of 
diseases in the newborn, which either present no visible local lesions 
at all, or are so slight as to escape attention in their early stages. 

Tetanus (Trismus) Neonatorum 

Tetanus in the newborn, like the corresponding disease in the adult, 
is due to the tetanus bacillus (Nicolaier, Kitasato). Infection usu- 
ally occurs through the umbilical stump or circumcision wound. The 
bacillus multiplies by spore formation and generates toxins which en- 
ter the system and are absorbed principally by the ending of the 
motor nerves. From here the toxins are ultimately carried to the 
anterior horns of the spinal cord and the nuclei of the medulla oblon- 
gata — hence the tetanic contractions. 

The symptoms begin within the first week after birth, or later 
after ritual circumcision, with restlessness, dropping of the nipple 
of the breast or bottle with a cry, and tension of the masseters. The 
spasm rapidly involves the orbicularis oris and palpebrarum muscles, 
the lower jaw becomes rigid, the mouth proboscidiform, the forehead 
and cheeks are wrinkled, and the eyelids are half closed (risus sardoni- 
cus). The hands are clenched, the legs flexed and abducted and, vary- 
ing with the degree of severity of the attack, there is more or less 
marked opisthotonos. At first the paroxysms occur only during the 
act of nursing, gradually, however, more frequently and more per- 
sistently. In severe cases there are also spasms of the glottis, of the 
esophagus, and diaphragm, and in consequence attacks of asphyxia 
which may end fatally. On the other hand, the affection may run 
a protracted course, sometimes for weeks, and occasionally end in re- 
covery. 



INJURIES AND DISEASES OF THE NEWBORN 



227 



The more violent the attacks and the higher the temperature, the 
less favorable the prognosis. Seventy per cent of the cases succumb 
within a few days, either from spasm of the diaphragm or, more rarely, 
from exhaustion. 

Treatment.— Careful protection against wound infection and prompt 
attention to existing traumatism. Considering the very grave prog- 
nosis under the ordinary methods of treatment and the occasional 
success obtained by means of hypodermic or subdural administration 
of tetanus antitoxin, the latter should be resorted to at the earliest 
possible time, either as a prophylactic immediately after the injury 




Fig. 56. — High degree of ' ' tetanism ' ; greatly resembling tetanus neonatorum. Xote 
Fig. 59, showing same ease during partial relaxation of the spasm. 

(500 units) or as a curative measure (2,000 units p. r. n.), in addition 
to the symptomatic treatment generally in vogue. 

The Department of Health of the City of New York suggests the 
following procedures in a developed case : 

A lumbar puncture having been performed in the usual way, 1000 
to 2000 units of antitoxin, heated to body temperature, are allowed to 
run into the spinal canal by gravity. In order that the antitoxin may 
be distributed throughout the length of the cord, it should, if necessary, 



228 DISEASES OF CHILDREN 

be diluted with sterile saline to a volume of at least 5 c.c. In case 
of a "dry tap," which has been reported on good authority as occa- 
sionally occurring in this disease, this amount should not be exceeded, 
but when an abundance of spinal fluid is obtained, the intraspinal dose 
should be little less than that of the fluid withdrawn. An intravenous 
injection of 3000 units should be given at the same time in order to 
render the blood highly antitoxic at once. The intraspinal injection 
may be repeated in 24 hours and again in 48 hours, but a third dose is 
probably unnecessary. A subcutaneous injection of 2000 units may 
also be given on the fourth day to sustain the antitoxic strength of 
the blood. If for any reason the attending physician is not able to 
give an intraspinal injection, an intravenous dose of 3,000 to 5,000 
units should be given. If this, too, is impossible, rather than delay, 
the same dose or a larger one should be given intramuscularly, sev- 
eral muscles being used, and arrangements immediately made to give 
an intraspinal and intravenous dose at the earliest possible moment. 
The use of antitoxin does not do away with the necessity for thorough 
surgical treatment of the wound if it has not already healed. The pa- 
tient should be protected as carefully as possible from noise, excessive 
light, drafts, jars, and other forms of irritation. Any irritation of the 
skin should be avoided. To combat individual symptoms we may resort 
to lukewarm baths, choral hydrate, the bromides per rectum, and heart 
stimulants, especially camphor. Feeding (mother's or diluted cow's 
milk) with a soft rubber tube through the nose. 

Arteritis and Phlebitis Umbilicalis 

This condition is usually observed secondarily to omphalitis (q. v.), 
but may occur as a primary disease. In the latter event no local alter- 
ations are discernible at the navel, and the grave affection frequently 
escapes notice until pronounced symptoms of general sepsis make their 
appearance. These consist of restlessness, fever, prostration and death 
within a few days, or gradual exhaustion from numerous complica- 
tions. In umbilical phlebitis intense icterus — from extension of the 
inflammation to the liver — forms a characteristic symptom. In some 
cases of arteritis and phlebitis umbilicalis a fistulous tract is observed 
at the navel which on pressure discharges blood and pus containing 
pathogenic microorganisms. 

For prophylactic and local treatment see "Omphalitis" (p. 221). The 
constitutional symptoms call for symptomatic treatment. Thus, care- 
ful feeding, preferably breast milk; active stimulation by means of 
enteroclysis, hypodermoclysis, sterile camphorated oil, etc. Antistrep- 
tococcic serum is deserving of trial. 



INJURIES AND DISEASES OF THE NEWBORN 229 

Erysipelas Neonatorum 

This affection begins suddenly, with high fever, convulsions, and 
often other symptoms of general sepsis. The glossy redness rapidly 
extends over large areas, often over the entire body. The disease 
proves fatal in a few days, and the cases that survive the acute attack 
usually succumb to cutaneous necrosis (particularly of the scrotum, 
extremities), copious diarrhea, septic peritonitis, pneumonia, and ex- 
haustion. 

The treatment is principally prophylactic. The inflamed areas 
should once a day be painted with pure ichthyol, or kept moist with 
gauze saturated with a 50 per cent solution of Epsom salts. In one 
desperate case under our care the rapid spread of the inflammation 
was arrested by painting the affected parts with pure carbolic acid 
followed by sponging with absolute alcohol. Antistreptococcus serum. 

Melena Neonatorum 

Helena vera should not be mistaken for melena spuria, in which con- 
dition the blood originates from erosions in the mouth or nasopharynx 
or from swallowing of blood from fissured nipples, etc. 

Melena vera usually begins in the first few days of the child's life 
with bleeding from the bowels, and often with hematemesis. As a 
rule, the blood is mixed with stool, and is dark brown or black in 
color. In some cases the loss of blood is slight, recurs at long in- 
tervals and terminates spontaneously without serious consequences 
except tedious convalescence. In the majority of cases of genuine 
melena, however, the bloody discharge is profuse and leads to rapidly 
increasing anemia and collapse. Eliminating the group of cases whioh 
are due to a hemophilic dyscrasia, authorities are not agreed on the 
actual cause of true melena. In a number of cases postmortem exam- 
ination disclosed erosions and ulcerations of the stomach and intes- 
tines which are attributed to thrombosis of the umbilical vein or the 
ductus Botalli. The consensus of opinion, however, favors the septic 
origin of the necrosis erosions. (For treatment see p. 230.) 

Epidemic Hemoglobinuria With Icterus in the Newborn 

(Cyanosis Icterica Cum Hemoglobinuria, Winckel's Disease) 

This extremely grave (90 per cent mortality) epidemic affection 
makes its appearance about the fourth day postpartum, in apparently 
healthy-born and well-developed children. The infant becomes rest- 
less, refuses nourishment, shows signs of respiratory disturbance and 
slight rise of temperature. The skin turns greenish yellow, and soon 



230 DISEASES OF CHILDREN 

deeply jaundiced and cyanotic. Collapse, somnolence and convulsions, 
rarely preceded also by vomiting and diarrhea (no blood), are rapidly 
followed by death. The urine is pale brown, contains hemoglobin, 
renal epithelium, granular and blood casts, and masses of detritus, 
but no free blood corpuscles. 

The autopsy reveals congestion and fatty degeneration of the inter- 
nal organs, with punctiform hemorrhages, especially in the mucous and 
serous membranes ; masses of granular hemoglobin in the kidneys and 
spleen and thickening of the blood. 

Acute Fatty Degeneration of the Newborn (Buhl's Disease) 

The essential anatomic features of this rare but very malignant af- 
fection are fatty degeneration of the internal organs, notably the heart, 
liver and kidneys, and hemorrhages in the viscera, and into the serous 
cavities. 

The disease attacks full-term infants who for some inexplicable rea- 
son are born asphyxiated. Those few who survive, respire badly, are 
cyanotic, or rather icteric, and present hemorrhages in the skin and 
mucous membranes, from the alimentary canal, and the umbilicus. 
They almost invariably succumb before the end of the second week 
from progressive anemia, anasarca, and collapse. 

Treatment. — The indications for the treatment of any of the afore 
mentioned hemorrhagic manifestations are: (1) to arrest the hemor- 
rhage ; (2) to improve or at least, maintain the vitality of the newborn 
infant. In former years considerable reliance was placed on a number 
of local hemostatics to arrest the hemorrhage, chiefly the actual cau- 
tery, adrenalin, perchloride of iron, ice and compression; for a time 
also calcium chloride internally and sterile, warm gelatine (10 per cent 
solution, 2 to 5 drams t. i. d.) hypodermically. Nowadays, however, 
all these doubtful procedures have been practically abandoned. 

Whether the hemorrhage be due to congenital hemophilia or sepsis, 
the best results are obtainable from subcutaneous injection either of 
blood serum 10 to 20 c.c. or whole blood (10 c.c. to 30 c.c. to be with- 
drawn from the vein at the bend of the elbow of a donor or parent), 
or both, after a short interval; or from direct transfusion. This last 
method is especially indicated in hemorrhage associated with sepsis ; 
but because of the extreme difficulty of doing a transfusion on a 
newborn, owing to the minuteness of the blood vessels, the operation 
should be performed by an expert. It has recently been shown that in 
infants the longitudinal sinus serves as an excellent, safe and easily 
accessible route for transfusion. The baby is immobilized as for in- 
tubation, the head is steadied by an assistant, and the sinus is 



INJURIES AND DISEASES OF THE NEWBORN 231 

reached by introducing (1 or 2 millimeters deep) a needle, 20 or 22 
gauge, one-half inch long. The injection of human serum or whole 
blood may be repeated every four to eight hours. Where human 
blood serum is not obtainable, horse or rabbit serum may be used in- 
stead. Transfusion may be performed by end-to-end anastomosis, by 
the Lewiston method of citrated blood, or by the direct Unger method. 
To meet the second indication the reader is referred to the in- 
structions given under the "Management of Feeble Vitality of the 
Newborn," p. 216. 

FUNCTIONAL DISORDERS OF THE NEWBORN 

(Uric Acid Infarct, Icterus, Mastitis) 
Uric Acid Infarct 

The urine of the newborn is clear immediately after birth, but 
turns turbid soon after and remains so for the first four or five days. 
It contains bladder and kidney epithelia, hyaline and epithelial casts, 
and a large quantity of urates. In consequence of the sudden altera- 
tion in the blood circulation there is an excessive excretion of nitrog- 
enous metabolic products, and as the newborn consumes but very 
little water during the first few days of life, uric acid crystals and 
ammonium urate, instead of being washed away, are retained in the 
renal tubules. 

The symptoms accruing from this functional insufficiency depend 
greatly upon the degree of obstruction of the urinary tubules. Or- 
dinarily, gradual elimination of the uric acid and ammonium urate 
crystals occurs within a few days without any abnormal manifesta- 
tions, except restlessness and crying just before and during the act 
of urination, and passage of small quantities of highly colored urine 
showing brick-red stains and a fine granular deposit on the diaper. Oc- 
casionally however, we find complete retention of urine, fever, and, 
owing to irritation of the renal pelvis, nephritis with its concomitant 
symptoms (albuminuria neonatorum). 

Treatment. — Large quantities of fluids, hot baths, mild diuretics. 

I£ Kalii acetatis 3ss. I 2.0 

Aq. fceniculi giij. | 100.0 

M. 

S. — 3i every hour if necessary. 

Icterus Neonatorum Catarrhalis 

The theories promulgated to explain the causation of icterus in the 
newborn are so numerous, pedantic and contradictory, that for the 



232 DISEASES OF CHILDREN 

sake of clearness, they are best left alone. It is perfectly logical to 
look upon this common (in about 80 per cent of all newborn infants) 
and harmless phenomenon as an expression of the active physiologic 
changes in the liver to which all other organs are subjected in the 
first few days of life. Hess believes the condition to be due to a con- 
gestion of the biliary capillaries resulting from an insufficient ex- 
cretion of bile into the duodenum. It would seem, however, plausible 
to assume that analogous to catarrhal jaundice in older children, icterus 
of the newborn is also a manifestation of gastrointestinal irritation, 
produced by the sudden demand upon the digestive system to exer- 
cise functions hitherto not accustomed to. 

The yellowish discoloration of the skin usually appears on the second 
or third day on the face and chest and gradually extends to the ab- 
domen and extremities and, rarely, also to the sclerse. The icterus 
runs an afebrile, uncomplicated course of about two weeks' duration. 
Cases of a more protracted course and presenting more or less severe 
general symptoms should always be looked upon as a partial manifes- 
tation of sepsis neonatorum. They may also be due to congenital 
syphilis, congenital obliteration of the bile ducts (q.v.), or possibly 
also to congenital cirrhosis of the liver. 

Mastitis Neonatorum 

Moderate swelling of the mammary glands of the newborn and dis- 
charge of a milk-like secretion ("witch's milk") is physiologic in in- 
fants of both sexes. It begins between the first and third weeks of 
life and may persist for weeks without giving rise to ill effects. Oc- 
casionally, however, as a result of traumatism or infection, it may 
terminate in acute inflammation or even suppuration. In this event 
the breasts are red, swollen and painful, and may present fluctuation 
at one or more points, and constitutional symptoms, such as restless- 
ness, vomiting, and fever. 

If the mammary glands are from the beginning not subjected to 
meddlesome interference, in short, are left entirely alone, there is 
usually spontaneous, gradual restitutio ad integrum. Should inflamma- 
tion ensue, the breasts should be wrapped in oiled cloths or absorbent 
cotton or gauze saturated with a 2 per cent boric acid or bichloride 
solution (1:10000), lightly painted with tincture of iodine, or covered 
with emplastrum belladonna? smeared on soft thin leather. In the 
event of suppuration, if not relieved by spontaneous evacuation of 
the pus, a radiate incision under aseptic precautions is indispensable. 

Phlegmonous inflammation and gangrene are rare complications, 
while atrophy of the mammary glands and more or less loss of func- 
tion may prove very serious to girls. 



CHAPTER V 
DISEASES OF THE ALIMENTARY TRACT 

DISEASES OF THE MOUTH 

Stomatitis 

Stomatitis or inflammation of the mucous membrane of the oral 
cavity is a more or less contagious affection peculiar to infancy and 
early childhood. It varies in intensity from simple temporary catarrh 
to fatal gangrene. It is invariably of parasitic origin. The degree 
of severity of the disease depends upon the pathogenicity of the para- 
site, the power of resistance of the patient, and the promptness and ac- 
curacy of the treatment. 

Stomatitis occurs principally at a time when the child's health is 
undermined, as, for example, during dentition, or synchronously with 
acute infectious diseases. Even normally the mouth forms a favorable 
nidus for cocci, bacilli, spirilla, leptothrix, and similar vegetations, 
and their growth is surely enhanced by allowing the child to enjoy 
its acrid nasal discharge; to suck on dirty nipples, toys, and eatables; 
by keeping its mouth and teeth filthy; by denuding the oral mucous 
membrane of its epithelium by brisk rubbing in the act of cleansing, 
and by permitting every friend or kin to infect the child's mouth 
by overindulgence in the art of osculation. Finally, dental caries, 
hemorrhagic affections, intoxication from the use of mercury, bismuth, 
etc., among many other diseased conditions, frequently form contrib- 
uting causes of stomatitis. 

In accordance with the seat and appearance of the lesion it is cus- 
tomary to distinguish the following varieties of the disease 

1. Stomatitis Catarrhalis (Erythematosa). — Redness and slight tume- 

faction of several portions of the mucous membrane of the mouth, 
coated tongue with prominent papillae and red tip and edges. Of- 
ten marked salivation. 

2. Stomatitis Mycotica (Soor, Thrush, Sprue). — Probably due to a 

hyphomycete, the Monilia Candida. Usually begins with a fine, 
white, flour- or casein-like deposit upon the slightly reddened 
tongue and buccal mucous membrane. The deposit may be yel- 
lowish or blackish in color. If not arrested, the dots and maculae 
coalesce and often extend to the pharynx, esophagus, stomach and 
intestines. This is apt to occur especially in atrophic children. 

233 



234. DISEASES OF CHILDREN 

3. Stomatitis Maculofibrinosa (Aphthosa, Follicularis, Herpetiformis). 

— The causal microorganism is still undetermined. Often begins 
with small vesicles. The inflamed mucous membrane is here and there 
(usually the anterior part of the mouth) covered with small, grain- 
to lentil-sized, variously shaped, yellow, grayish-yellow, or grayish- 
white foci surrounded by a dark-red areola. By coalescence of 
several follicles, large raised plaques are sometimes observed. 
Fetor ex ore. 

4. Stomatitis Ulcerosa (Stomacace). — It is attributed to the Bacillus 

fusiformis and the Spirochaete denticola. The lesion consists of 
numerous, grayish, irregular, ulcers with a bleeding base and angry- 
looking areola, situated at first on the red, spongy and painful 
gums, and, if not arrested, spreading to the tongue, cheeks or lips 
and tonsils. Fetor ex ore. In bad cases also the teeth loosen and 
the lymph nodes swell. 

This form of stomatitis differs, from the yellowish to greenish, super- 
ficial, easily bleeding ulcers, known as Beclnar's aphthce (ulcera ptery- 
goidea), of the newborn or young infant, by the fact that the latter 
appear symmetrically on each side of the median raphe near the junction 
of the hard and soft palates, and are usually the result of abrasion of 
the epithelium by too strenuous cleansing of the mouth. 

It may occasionally also be mistaken for the exceptionally ulcerating, 
so-called "epithelial pearls." These innocent milia-like dots, however, 
are usually found only in the newborn, and situated along both- sides of 
the raphe of the palate. 

5. Stomatitis Gangrenosa (Noma Faciei, Cancrum Oris). — It occurs 

principally in cachectic children, chiefly between two and five 
years old. It may follow ulcerative stomatitis or acute exanthem- 
atous diseases (measles!) and begins with a small, rapidly spreading 
brownish, greenish ulcer upon a hard, elevated base, on the inner 
surface of the cheek, near the angle of the mouth or on the lips. 
Very soon a black spot appears on the outside of the cheek, sur- 
rounded by marked tumefaction of that side of the face and the 
submaxillary glands. The cheek becomes perforated, the edges 
of the wound turn black, and the sloughing process spreads rap- 
idly so that the whole thickness of the cheek has the appearance 
of a dirty, greasy scab, and within a few days may be completely 
destroyed. Also necrosis of the jaw and general toxemia. Rapid 
exhaustion. 

In addition to these definite varieties of stomatitis, Ave occasionally 
meet with involvement of the oral mucous membrane as a result of 




PLATE III 

Stomatitis Aphthosa (Advanced Stage) 

(Courtesy of Dr. John Zaliorsky.) 



DISEASES OF THE ALIMENTARY TRACT 235 

diphtheritic or gonorrheal infection, as also a pseudomembranous 
form arising from traumatism and subsequent streptococcic infection 
of the mucous membrane. This last variety is not rarely observed 
in the newborn, occasionally forming a partial manifestation of sep- 
sis neonatorum (q. v.) 

Mild or even moderately severe cases of stomatitis rarely give rise to 
systemic disturbance, and unless the local lesion is situated on the lips, 
tongue, or gums and interferes with sucking, or chewing, several days 
may pass before the disease is detected. Sometimes the patient is 
feverish and restless, cries and refuses food in the earliest stage of 
stomatitis, but the constitutional symptoms do not stand in direct 
ratio to the extent and gravity of the local manifestations. However, 
with persistence of the local symptoms, sooner or later the general 
health participates in the pathologic process. Starch digestion is 
greatly impaired by the excessive loss of saliva, which almost inces- 
santly dribbles from the swollen, reddened, half-closed lips, and vom- 
iting and severe diarrhea are frequent results of swallowing of the 
putrid saliva and the decomposing, more or less ichorous and membra- 
nous oral contents. These latter symptoms, in addition to the emacia- 
tion from refusal of food and absorption of septic material, greatly 
delay convalescence and may lead to gradual or rapid exhaustion and 
fatal issue. In the absence of such grave symptoms and with early 
and careful treatment, however, the prognosis is good in all forms of 
stomatitis, except noma (75 per cent mortality). 

Treatment. — Above all, cleanliness should be enforced, and the sooner 
it is begun the surer we are of rendering the disease free from unto- 
ward consequences. Strictest cleanliness of the food, feeding-bottles 
and nipples, cups, spoons and everything else coming in contact with 
the child's mouth, should be observed. The child's mouth should be 
regularly washed after each feeding, by gently wiping it with absorbent 
cotton dipped in a 2 per cent watery solution of boric acid or bicar- 
bonate of soda. As to general cleanliness, see "Hygiene," p. 64. 

In mild cases it is usually sufficient to paint the affected parts once 
a day with a 2 per cent solution of nitrate of silver and to employ 
the following- mouth wash everv two to four hours: 



J£ Acid boriei, 



4.00 



Sod. boratis a a 3j. 

Hydrogen dioxidi, 

Glyeerini aa 5j. 

Alcoliolis 3iv. 

Aq. rosae q. s. §iv. 

M. 
S. — To be diluted "with an equal quantity of water, as a mouth-wash. 



30.00 

15.00 

120.00 



236 DISEASES OF CHILDREN 

Should the stomatitis fail to yield to the treatment after twenty- 
four to forty-eight hours, more energetic measures should then be 
adopted to stay its destructive tendencies. The strength of the silver 
solution should be doubled, and the mouth irrigated every two hours 
with 1 per cent permanganate of potash, 5 per cent Labarraque's 
solution, % to 1 per cent of chlorazene or Chloramine T (Dakin's anti- 
septic), etc. 

It is often advantageous to suspend milk feeding for a few days 
and to nourish the child on broths, light cocoa, cereals, toast and tea, 
pineapple juice, etc. Protracted illness demands active stimulation by 
means of good wines (diluted), strychnine, and compound tincture of 
cinchona. This may be combined with the rhubarb and soda mixture 
to remedy gastrointestinal disturbance which is ever present in cases 
of long standing. In the majority of instances even severe cases of 
stomatitis promptly respond to this mode of treatment. An exception 
to this rule is made, however, by noma, — that rapidly advancing form of 
necrosis, which knows no barrier to its destructive, death-dealing trail, 
and often even the knife fails to stay its ravages. At the earliest 
possible moment the gangrenous portion should be destroyed with the 
caustic stick, nitric acid or, preferably, with the actual cautery. Fre- 
quent cleansing of the parts should be continued day and night, and 
strengthening food and stimulants administered at short intervals. 
Since Loemer's bacilli are found in a number of cases of noma 
faciei and vulvae, diphtheria antitoxin (5 to 10,000 units) shojild be 
resorted to early in the course of the disease. Very often everything 
fails; fatal issue occurs either after two or three weeks (sometimes 
when the patient is apparently saved) or, more rarely, suddenly as a 
result of entrance of air into the veins. Eadical operation has recently 
received enthusiastic advocacy. 

Dentitio Difficilis 

(Difficult Teething) 

As a rule, normal children get their teeth without any difficulty. 
They may show a slight indisposition in the form of fretfulness, dis- 
turbed sleep and slight loss of appetite. If care is being taken not to 
overfeed the baby during its teething period and the mouth is kept 
free from outside infection, there is rarely any need for special 
therapeutic measures. On the other hand, infants of low vitality and 
more especially those who had been suffering from gastroenteric dis- 
turbances or rachitis previous to the eruption of a tooth, teething, 
particularly if several teeth come at once, is very apt greatly to ag- 



DISEASES OP THE ALIMENTARY TRACT 237 

gravate the diseased conditions. But even in these children neglect 
in the general care of their health is responsible to a great extent 
for the serious consequences. Most people are so strongly imbued 
with the idea that teething is the sole cause of gastroenteritis, bronchi- 
tis, otitis, and what not, and that it must be so as a matter of course, 
that they complacently wait and watch for the teeth to protrude, and 
seek no medical aid to stay the ravages of the incidental ailments. It 
is usually in these cases that hyperpyrexia and convulsions are en- 
countered, and that remedial measures have to be employed to facili- 
tate teething, as it were. 

Of course there are infants (see "Spasmophilia," p. 668) who will 
get convulsions, high fever, etc., on the most trifling provocation, and 
hence teething also is contributing its share in this direction, but all 
these extraordinary manifestations are no doubt exceptional. 

The main points, therefore, are to reduce the food, to keep the child 
outdoors, and to avoid so-called "soothing syrups," which almost in- 
variably contain opiates or similar stupefiers that depress the infant's 
vitality. 

When the gum is very much swollen and the tooth visible directly 
under the mucous membrane, brisk friction (with rough end of sterile 
teaspoon) or even lancing of the gum does no harm and may relieve 
some reflex nervous symptoms. 

DISEASES OF THE SALIVARY GLANDS 

Salivation 

Increased salivary secretion is almost physiologic during first denti- 
tion, and is the result of increased blood supply to the oral mucous 
membrane. Pathologically it is observed in stomatitis, cretins and 
other mentally deficient children; in helminthiasis and mercurial in- 
toxication. Occasionally it is met with in apparently healthy children 
long after first dentition ; and in the absence of any discernible cause 
it is attributed to a neurosis. In view of the harmlessness of the 
condition per se, no special treatment is indicated except protection of 
the chin and chest against the irritating effect of the constantly dribbling 
saliva, and removal of the causes wherever found. 

Ranula 

Retention cysts, congenital or acquired, are not rarely observed in 
children, and are the result of obstruction of the salivary ducts. Most 
frequently a globular, usually unilateral, tense, cystic swelling is 
found on the floor of the oral cavity, sometimes close to the frenulum. 



238 DISEASES OF CHILDREN 

This tumor which is designated ranula, varies in size from a pea to a 
pigeon's egg and contains a thin or viscid fluid. If large in size, the 
tumor interferes with suckling, swallowing and breathing, and calls for 
its incision and cauterization, or complete excision. 

Eanula is not to be confounded with the peculiar sublingual growth 
(Riga's or Fecle's disease) quite frequently observed in Italy* among 
nurslings. This neoplasm is usually situated at the insertion of the 
frenum lingua?, attains almost the size of a five-cent piece, and shows a 
tendency to return unless completely extirpated. 

Secondary Parotitis 

This form of inflammation of the parotid gland may occur in con- 
nection with acute infectious diseases. It differs from epidemic mumps 
(q.v.) in being, as a rule, unilateral. It heals spontaneously within a 
few days, or ends in suppuration, in the latter event requiring operative 
interference. 

DISEASES OF THE TONGUE 

Glossitis 

Aside from the divers pathologic conditions of the tongue ordina- 
rily met with in connection with stomatitis, tonsillitis, pharyngitis, 
exanthematous affections, etc., the tongue is subject to the following 
peculiar diseases: 

1. Glossitis Marginalis Erythematosa. — The inflammation is usually 
limited to the edges of the tongue which are red and partially denuded 
of epithelium. It is observed in artificially fed infants, and is probably 
the result of mechanical irritation from the act of sucking, and more 
particularly from the constant use of the "pacifier." 

The treatment is the same as for mild stomatitis. 

2. Glossitis Areata Exfoliativa (Annulus Migrans, Ringworm of the 
Tongue, Lingua Geographica) . — As a rule, it begins with a brownish 
thickening at the margin of the tongue, and, by gradual spreading, 
forms irregular, circumscribed lines, resembling, as the name indicates, 
a geographical map. Now and then part of the thickened epithelium 
is thrust off, but new places are soon involved, and in this manner the 
affection may go on for years, without, however, giving rise to ulcera- 
tion of the tongue or any constitutional symptoms. It is not, as was 
frequently supposed, a sign of syphilis. 

The treatment consists of cleanliness and occasional painting with 
a strong solution of chromic acid. (See "Stomatitis.") 



*Only a few such cases have thus far been observed in this country. 



DISEASES OF THE ALIMENTARY TRACT 



239 



DISEASES OF THE ESOPHAGUS 

Esophagitis 

Primary inflammation of the esophagus is comparatively rare in 
children, since the principal cause of the disease in the adult, i. e., 




Fig. 57. — Penny in esophagus of an infant readily extracted under the guidance of 

the roentgen ray. 

corroding of the esophagus by caustic poisons taken with suicidal in- 
tent, is of exceptional occurrence. However, it is occasionally met 
with in connection with accidental injuries, such as impaction of for- 
eign bodies, unintentional swallowing of caustics, etc., or scalding by hot 



240 DISEASES OF CHILDREN 

fluids. The accompanying symptoms vary with the extent of the in- 
jury. They consist chiefly of dysphagia, tendency to vomit, and ex- 
pectoration of bloody, membranous masses. In severe cases, if the pa- 
tient at all survives from the immediate effects of the injury (fre- 
quently fatal collapse), the esophagitis runs a very protracted course 
and produces secondary esophageal strictures (q. v.). 

Secondary esophagitis occurs as an extension of inflammatory, espe- 
cially diphtheritic, processes of the mucous membrane of the mouth and 
pharynx. 

Treatment. — Antidotes in cases due to corrosives, morphine hypoder- 
mically for the relief of pain and shock, ice collar to the neck and ice 
by mouth to subdue the inflammation, and stimulants whenever indi- 
cated. 

Stenosis Esophagi. — Esophageal strictures may be congenital (q. v.) 
or acquired, the latter being the result of esophagitis (q. v.). De- 
pending upon the severity of the injury the stricture may advance 
up to total atresia. In children the stenosis is most frequently situ- 
ated in the upper third of the esophagus, and may occasionally be 
detected by esophagoscopy. Otherwise the diagnosis is established 
by introduction into the esophagus of an elastic catheter or whalebone 
provided with a small olive-shaped steel tip. For this purpose the pa- 
tient is placed in a sitting posture with the head extended slightly back- 
ward. The oiled instrument is guided with the first two fingers over 
the dorsum linguae and the epiglottis into the esophagus. 

In acquired stenosis the symptoms usually appear about two weeks 
after the injury and consist chiefly of difficult deglutition and gradual 
loss of weight. In cases of stenosis due to compression of the esophagus 
by diseased neighboring organs or tumors the symptoms are, of course, 
more gradual in their development and more intricate in nature agree- 
ing with the primary cause. 

Treatment. — Partial stenoses often yield to dilatation by means of 
bougies, provided the dilatation is continued two or three times a week 
for at least six months. The bougie is left in place for from five to 
thirty minutes. Occasional introduction of the bougie after apparent 
cure will prevent recurrences. Great care and patience are required to 
prevent perforation. Gavage and nutrient enemata are used if neces- 
sary. In severe and recurrent strictures operative interference (esopha- 
gotomy or gastrotomy) are in order. Good results are claimed from the 
use of thiosinamine : five drops of a 10 to 15 per cent glycerinated 
watery solution may be injected hypodermically twice a week in addition 
to the dilatation previously spoken of. Thiosinamine may also be given 
by mouth (y 2 gr. t. i. d.) and applied locally. 



DISEASES OF THE ALIMENTARY TRACT 241 

DISEASES OF THE STOMACH AND INTESTINES 
General Etiology 

With the recent advances in bacteriology and physiologic chem- 
istry and corresponding improvements in sanitation and infant feed- 
ing, cow's milk no longer holds the record of "Wuergengel" (destroy- 
ing angel) of the poor innocent babes. Indeed, a case of gastroenteritis 
is seldom met with which is not primarily traceable to some gross error 
of diet entirely independent of the cow's milk feeding. The sooner the 
physician will appreciate that fresh, unpolluted, properly modified, (as 
to quality and quantity), well kept, and regularly administered cow's 
milk is not inimical (except, of course, in the comparatively rare cases 
of so-called "cow's milk idiosyncrasy" from birth) to good health and 
perfect development of the child, the better will he be prepared to re- 
veal the etiologic factors of the gastrointestinal disturbance and com- 
bat them! 

On the other hand, cow's milk, especially in the hot season of the 
year, whether contaminated at the dairy or at the filthy shop of the 
remorseless vendor, may form, like water, an excellent vehicle for the 
dissemination of pathogenic bacteria, and for the spreading of infec- 
tious gastroenteric affections. 

Whatever the vehicle of transmission, — be it decomposed milk, fruit, 
vegetables, or meats; infected water, feeding bottles or nipples, cups 
or spoons, toys or fingers; infectious discharges from the mouth or 
nasopharynx, etc., — careful investigation has established the fact 
that most, if not all, acute gastrointestinal diseases are primarily or 
secondarily due to microbic invasion of the alimentary canal, the se- 
verity of the affection more or less corresponding to the pathogenicity 
of the invading microorganisms. 

The bacteria responsible for the production of gastrointestinal dis- 
eases are very numerous. Streptococci, the B. coli communis, B. dysen- 
teriae liquefaciens, (Shiga, Kruse and Flexner). staphylococci, B. in- 
fluenzae, B. pyocyaneus, B. proteus, among many others, contribute 
their share as etiologic factors. The determination of the specific germ 
of each type of gastrointestinal disease, however, is still a matter of ex- 
perimental research and subject to great diversity of opinion. 

Gastroenteric disorders in breast-fed babies may occur, in addition to 
errors of diet and exposure to infection — less frequent causes than in 
hand-fed babies — as a result of disturbance of the quality of the breast 
milk by disease, fright, grief, privation, pregnancy, and like influences 
on the part of the mother, or the wet nurse. 



242 DISEASES OF CHILDREN 

Finally, even in most carefully fed infants, gastrointestinal disorders 
are occasionally encountered where the alimentary canal is functionally 
or anatomically defective from birth {e.g., pylorus stenosis), or where 
the infant is suffering from diseases of the other organs of the body, or 
is indisposed from the effects of functional or organic alterations asso- 
ciated with normal bodily development (e. g., dentitio difficilis). 

Stenosis Pylori Congenita 

(Pylorospasm) 

Stenosis of the pylorus may be complete or partial. 

Complete atresia is extremely rare and invariably fatal from com- 
plete starvation within a few days after birth — sometimes before the 
diagnosis can be established. 

Partial stenosis of the pylorus, on the other hand, is a comparatively 
frequent affection which not rarely terminates in recovery, either 
spontaneously or through medical and surgical treatment. It is dis- 
tinguishable in two forms : True and false. 

1. True or hypertrophic stenosis is invariably due to a congenital nar- 
rowing of the lumen of the pylorus and is associated with more or less 
'primary hypertrophy of the pyloric ring and secondary dilatation of 
the stomach. 

2. False or spastic pyloric stenosis (pylorospasm) is the result of con- 
genital faulty innervation of the stomach, or of acquired digestive and 
nervous disturbances. It is free from primary hypertrophy of the py- 
loric ring. Sooner or later secondary hypertrophy of the muscular and 
mucous coats of the stomach occurs in consequence of the increased 
force required by continued muscular contraction of the stomach to 
propel the ingesta. At a later stage of the disease the stomach walls 
lose their tonicity and dilatation is the usual consequence. 

The clinical picture of the disease is very typical. The apparently 
fully developed infant at birth, after a period of wellbeing of from a half 
to three weeks or even longer, begins to vomit sometimes after each 
feeding or after several feedings. The vomiting rapidly becomes very 
violent in character, and the contents of the stomach, which appear 
greater (ischoeliymia — retention of digested food) than the child could 
have taken in one feeding, consists of a hyperacid* mixture of mucus, 
digested and undigested fcod, free from bile, and is explosively ejected 
(projectile vomiting). As an immediate result of the vomiting, the 
intestinal tract remains empty ; hence, absolute constipation, (but in fact 
only pseudoconstipation) or only occasional evacuation of a small quan- 



*In two cases under our observation there was total aehylia gastrica. 



DISEASES OF THE ALIMENTARY TRACT 



243 



tity of brown, bile-stained, foul-smelling fluid. The urine is scanty 
and concentrated. The infant acts very hungry, voraciously swal- 
lows a few mouthfuls of food but being seized by sudden spas- 




Fig. 58. — Pylorus stenosis in a boy three months old under observation of the 
author through the kindness of Dr. J. L. Rubinstein. Note almost complete closure 
of pylorus after bismuth test. Patient recovered fully after operation. 



244 DISEASES OP CHILDREN 

modic pain, it drops bottle or breast, only to grasp it again after some 
relief is obtained. The abdomen is sunken, while the epigastrium is 
distended, and here and there are visible peristaltic movements (hyper- 
kinesis) of the stomach, from left to right. The peristalsis can be seen 
and felt only after the infant has become greatly emaciated. Occasion- 
ally the peristaltic movement is reversed, i. e., from right to left. The 
peristaltic stomach wave is best obtained by washing the stomach and 
allowing 2 ounces of water to remain, or giving 2 ounces of food. If the 
patient is given a pacifier and is then placed on his back with the light 
favorable for observation, the wave phenomenon will shortly appear 
(Kerley). In most cases a small tumor — the hypertrophied pylorus — is 
palpable at the pyloric end of the stomach a little above and to the 
right of the umbilicus, or lower down after the stomach has become 
very much dilated. 

In early stages of pylorospasm the symptoms are less pronounced, 
vomiting is less frequent, and the stools contain some curds and hardened 
feces, but otherwise cannot be easily distinguished from true pyloric 
stenosis except by Roentgen-ray examination. In pyloric obstruction, 
bismuth subcarbonate (administered through a tube) will fail to enter 
the intestines, or do so only after a period of twenty-four hours and in 
very minute quantities. Less reliable is the charcoal test. This consists 
in the administration by the stomach tube of 10 grains of charcoal in 2 
ounces of water and examining the contents of the stomach for the 
charcoal twenty-four hours later. 

The course of the affection varies with the degree of contracture. In 
the majority of instances the true form of the disease, if not operated 
upon early, terminates fatally in from four weeks to four months, with 
symptoms of inanition, acidosis, and collapse, or pneumonia. Oc- 
casionally, however, a change for the better occurs and slow recovery 
follows. This is particularly apt to take place in spastic pyloric steno- 
sis, especially if early and properly treated. With these facts in view, 
it is extremely difficult to decide when and whether surgical inter- 
vention is indicated. The profession is greatly divided on this question. 
The statistics adduced for and against an operation seem to favor both 
contentions. The surgical ' ' cures ' ' do not always assure us of their per- 
manency. A little patient of mine, nine weeks old, recently operated 
upon, did well for six days, but died two days later from the effects of 
a minute gastrointestinal fistula. Two of my patients were operated 
upon apparently successfully, but died suddenly a few weeks later. On 
the other hand, who can vouch for the permanency (remissions are not 
rare !) of the medical "cures," and for the correctness of the diagnosis in 



DISEASES OF THE ALIMENTARY TRACT 



245 



such cases! H. Lowenberg offers the following very valuable observa- 
tions, as to the type of cases demanding operative treatment. 



NONSURGICAL 

1. Weight curve resembles curve of 
continued fever with slight remissions 
and elevations. At the end of a week it 
is stationary, or but slight loss or gain 
is recorded. 

2. General strength is not materially 
reduced at end of this time. 

3. Bowels are constipated but move- 
ments are of fair size and contain curds 
or digested milk. 



4. Recovery of considerable quantity 
of charcoal in rectal discharges, al- 
though its passage is delayed. 

5. Nonrecovery, or recovery of but lit- 
tle charcoal in the stomach washings 
twenty-four hours later. 



6. X-ray examination reveals more or 
less bismuth in the small and large in- 
testines. 



7. Severity of vomiting is intermittent 
and often yields to gastric lavage. 

8. Constantly palpable, except before 
mittently so. 



SURGICAL 

1. Weight curve resembles the crisis 
of a pneumonia. End of a week records 
a loss of 8 to 10 ounces or more. 



2. General strength fails rapidly. 



3. Constipation absolute or nearly so. 
Movements are ordinarily of bile- 
stained mucus, sometimes very small 
amounts of milk feces. 

4. Nonrecovery of charcoal, or very 
little at end of thirty-six to forty-eight 
hours and continuing for many days. 

5. Recovery of considerable quantity 
of charcoal in the stomach washings 
twenty-four hours or more after admin- 
istration. 

6. X-ray pictures taken in series for 
a period of twenty-four hours show re- 
tention of bismuth in the stomach, and 
not any or only traces in the small and 
large intestines. Bismuth shadow has a 
' ' comet ' '-like appearance. 

7. Constant, and not influenced by gas- 
tric lavage. 

8. Constantly palpable, except before 
emaciation occurs. 



An operation, if indicated, should not be delayed until the child is 
at death's door. The choice between divulsion (Loreta), pyloro- 
plasty, gastroenterostomy, posterior gastrojejunostomy and the Eamm- 
stedt operation (splitting of the pylorus longitudinally down to but 
not through the mucosa), depends upon the pathologic condition of 
each individual case, and the judgment of the surgeon. 

In reviewing one hundred and seventy-five cases of plyoric stenosis 
in which the Fredet-Rammstedt operation was performed, W. A. 
Downes* offers the following suggestions: 



*Jour. Am. Med. Assn., July 24, 1920. 



2-46 DISEASES OF CHILDREN 

1. If the patient is observed from the onset of symptoms, medical 
treatment may be tried for a period of not longer than ten days, pro- 
vided the weight loss does not exceed 20 per cent during this time. If, at 
the end of this period, the child does not show definite improvement, 
operative interference is indicated. Any patient, continued under medi- 
cal care, and suffering a relapse should be operated on at once. 

2. All cases in which there is a history of a period of ten days or 
longer in which the data as to previous weight are lacking — and in 
which the patient is not in very good condition — should immediately be 
classed as surgical. 

3. The mortality among patients coming to operation within four 
weeks from the onset of symptoms is less than 8 per cent. 

4. The results following the Freclet-Rammstedt operation are perma- 
nent and the cure complete. 

The Rammstedt operation is highly recommended by E. Feer. Du- 
four and Fredet have collected 36 cases operated by the Rammstedt 
method with 9 deaths. Kerley reports 26 cases with 4 deaths, and 
believes that operation by the Rammstedt method will insure a mor- 
tality of only 5 per cent in patients who have not vomited more than 
two weeks, provided, of course that adequate after-care, which in- 
cludes the use of breast milk, is supplied. He recommends the fol- 
lowing postoperative management^ as evolved by Holt and W. L. 
Downes. The infant is wrapped in a warm blanket before leaving 
the operating room and when in bed is surrounded by hot water 
bottles outside the blanket. For an hour or two following the operation, 
the head of the bed is kept lowered to prevent aspiration of mucus into 
the larynx. This is absolutely necessary while the infant is still under 
the influence of the anesthetic, When nourishment is commenced, the 
head of the bed is raised to a level position. Ten or twelve hours later 
the patient is placed in a semierect position, which tends to prevent re- 
gurgitation of food and permits the more easy escape of gas. 

As soon as the patient is placed in bed, a hypodermoclysis of 120 
c.c. of physiologic sodium chloride solution is given, and if the condition 
is poor, a hypodermic of 5 minims of epinephrin, 1 :1,000, is given and 
repeated in from four to five hours. Dilute whiskey, 5 minims every 
three hours for the first five or six days, has proved of great value. 
Transfusion in a few cases of collapse has been of material benefit, from 
80 to 120 c.c. of blood from either parent being given preferably into 
the median basilic vein. 

One and one-half hours after operation, provided the patient has 
sufficiently recovered from the anesthetic, 10 c.c. of water are given, and 
one and one-half hours later, 4 c.c. of barley water and 4 c.c. of breast 



DISEASES OF THE ALIMENTARY TRACT 247 

milk. Two hours later, 8 c.c. of breast milk and 4 c.c of barley water 
are given. Breast milk is then given every three hours, alternated with 
water, and gradually increased in amount so that at the end of forty- 
eight hours about 30 c.c. are given at a feeding, with 4 c.c. of barley 
water. The barley water is then discontinued, and on each successive day 
the amount of milk permitted is increased 5 c.c. at a feeding, so that by 
the eighth day following the operation the patient is having 60 c.c. every 
three hours. On the third day the intervals of feeding at night are 
lengthened to four hours, so that seven feedings are given instead of 
eight. By the time the baby is taking 60 c.c. of breast milk at each feed- 
ing, he may be put to the breast once. The baby is weighed before 
nursing and at intervals of three minutes until he has nursed 60 c.c. 
from the breast. The following day three nursings are allowed, so that 
by the eleventh or twelfth day the patient is nursing entirely and is 
able to leave the hospital. Measurement of food during the nursing 
must be kept up one week later by carefully weighing the baby both 
before and after nursing. For one month or longer a wet nurse is ad- 
visable if the mother is not able to nurse her child. 

In well-nourished infants, a sponge bath is given daily until the 
wound is completely healed. In emaciated children, an oil rub is pref- 
erable until such time as the tendency to subnormal temperature has 
passed. 

In cases of vomiting due to accumulation of gas in the stomach, the 
child should be raised to an upright position after feeding. If this 
does not suffice, a soft rubber catheter may be passed into the stomach 
before each feeding. If still persistent, gastric lavage niay be employed. 
One teaspoonful of castor oil is usually given twenty-four hours after 
operation if there have been no stools. There should be from two to 
three stools a day. If they are more frequent, protein milk may be 
substituted for three or four breast feedings. 

The wound is covered with a narrow fold of sterile gauze held in 
place by adhesive strips. It is not disturbed for four or five days, unless 
some indication arises. The stitches are removed on the ninth or tenth 
day. 

The nonsurgical treatment of congenital pyloric stenosis must be car- 
ried out systematically and faithfully. "Whenever possible, the infant 
should be fed on woman's milk, (after removal of fat), preferably with a 
spoon or tube,* in order to gauge the amount of food consumed, and possi- 
bly retained, by the infant and also to avoid contractions of the stom- 
ach by the act of sucking. The amount of feeding should not exceed 



*P. Hertz (Ugeskr. f. Laeger, June 13, 1918) recommends duodenal feeding by means of 
a Xelaton catheter, Xo. 18 or 19, giving as much as 2 to 3 ounces at each feeding. 



248 DISEASES OF CHILDREN 

one ounce, but may be given every hour or two, so as to sustain 
the child's vitality. Modified or predigested milk may be administered 
instead of woman's milk if the latter is not readily obtainable. In view of 
the fact that almost two-thirds of the cases of pyloric stenosis thus far 
reported were breast-fed babies, one is tempted to recommend fat-free 
cow's milk feeding as a therapeutic or, at least, as a prophylactic meas- 
ure against pyloric stenosis. Indeed, following the temptation in 2 of my 
own cases, I was — perhaps accidental^ — rewarded with happy results. 
May I venture to suggest that the large curd of cow 's milk tends mechan- 
ically to dilate the contracted pyloric orifice ? and, furthermore, that the 
fat breast-milk is possibly a cause of pylorospasm? 

Reduction in the frequency of the attacks of vomiting and in the 
amount ejected forms the first and best indication of improvement in' 
the condition. Next to careful feeding, systematic washing of the child's 
stomach serves as the sheet-anchor in the therapeusis of congenital py- 
loric stenosis. It should be practiced at least twice a day with plain, cool 
(70° to 80° F.) water, occasionally adding a small amount of bicarbon- 
ate of soda to neutralize the hyperacidity of the stomach. The washing 
should be continued until the water returns clear. The effects of the 
lavage are the removal of decomposing substances from the stomach, 
arrest of fermentation and the allaying of pain and spasm. For the lat- 
ter purposes, prolonged warm baths and hot compresses to the epigastric 
region are also very useful. To counteract the excessive loss of fluids, 
a daily enteroclysis or hypodermoclysis is of advantage. Internal 
medication is of little value, except anodynes for the relief of pain 
and spasm. For this purpose minute doses of codeine with or without 
belladonna may be administered in the form of suppositories. 

■S. V. Haas (Aim. Jour. Dis. Child., May, 1918) prefers atropine owing 
to its paralyzing effect on the vagus nerve endings. In the course of 
twenty-four hours he administers from 1/50 to 1/25 of a grain with an 
extreme of 1/16 of a grain, divided among the whole day's feedings. 

Skillful nursing, privately or in a hospital, should be insisted upon. 

I. Acute Gastroenteritis 

(Indigestion, Dyspepsia) 

Classification 

In accord with the aforementioned general etiology (see p. 241) 
gastrointestinal disease in infants and young children may be classi- 
fied as follows : 

1. Dyspepsia ex aliment at ione, or faulty assimilation of the food, as a 
result of : 



DISEASES OF THE ALIMENTARY TRACT 249 

A. Overfeeding or too frequent feeding in general, or 

B. Overfeeding with a milk mixture containing too much of : 

a. Fat, b. Carbohydrates, c. Proteins. 

2. Dyspepsia ex infectione, due to: 

A. Direct infection of the intestinal tract, (enteral). 

B. Indirect infection (parenteral), i.e. secondarily to other diseases. 

3. Dyspepsia ex constitutions, in consequence of: 

A. Congenital deficiencies 

a. Organic, e. g., pylorus stenosis, megacolon. 

b. Functional or constitutional dyscrasia, e. g., exudative diathesis. 
As the other varieties of gastrointestinal affections are fully described 

in other parts of the book (see pp. 521, 522) we will here limit our dis- 
cussion to the infectious gastroenteric affections. 

Occasional vomiting and diarrhea, occurring as a result of unusual 
overloading of the stomach, too hasty feeding, the partaking of indi- 
gestible articles of food (raw, unripe fruit, peels and parings), or for- 
eign bodies, exposure to sudden atmospheric changes and undue excite- 
ment, etc., are not rarely observed in otherwise apparently healthy, 
well-nourished children, and if of brief duration, are of no special clin- 
ical significance. These attacks may even be accompanied by fever, 
mild cerebral irritation, colic, etc., and yet remain outside the domain 
of pathology, or represent an affection which is generally spoken of as 
simple indigestion or the first stage of gastroenteritis. By avoiding 
further transgressions of the ordinary dietary and hygienic rules, and 
by removing the causal obnoxious influences, recovery is usually prompt 
and permanent. 

If, however, the vomiting and diarrhea persist or recur at frequent 
intervals; if the child loses its appetite and some of its weight; if its 
tongue becomes heavily coated, its abdomen greatly distended and its 
general health more or less seriously impaired ; if the infant suffers from 
severe abdominal pain after each feeding and vomits part of the food 
consumed and some mucus and bile; finally, if the stools rapidly increase 
in number and consist of masses of undigested food, of bad color and 
offensive odor, a symptom-complex develops which represents the second 
stage of gastroenteritis and is generally described as gastrointestinal 
catarrh or dyspepsia. 

Ordinarily these manifestations set in insidiously, and, if not promptly 
arrested, grow worse gradually, arousing little if any anxiety on the 
part of those in charge of the baby, or are lost sight of, sometimes because 
of coincident "teething" (with the laity the presumptive cause of all 
ills), until there is a sudden aggravation of the condition — superven- 
tion of the third stage of the disease. 



250 DISEASES OF CHILDREN 

In this stage, gastroenteritis assumes a very acute course. It is mani- 
fested by violent vomiting, excessive thirst ; frequent, thin watery, brown- 
ish, greenish, and later colorless or blood-stained stools. The vomitus 
is acid in reaction, bile stained, and offensive in odor. The bowel move- 
ments vary between ten to fifteen in twenty-four hours, are preceded 
and followed by griping pain and tenesmus. The child is very restless, 
feverish, sleepless, and, with the symptoms persisting a few days, rapidly 
loses in weight, and sinks into a state of collapse, followed by convul- 
sions, coma and death. More favorable cases may improve under 
energetic treatment (see "Cholera Infantum," p. 251), or linger for 
weeks or months, frequently suffering from intense exacerbations of 
the attacks, and, finally, either recover after tedious convalescence or 
die from inanition or complications. 

Cholera Infantum 

(Summer Complaint) 

Closely allied to the gastroenterocolitis just described (though possibly 
differing as to the exciting microorganism — probably the dysentery ba- 
cillus, but also the gas bacillus or streptococcus), and probably repre- 
senting only a severer, "fulminating" form of the same disease, is the 
so-called infantile "summer complaint" or cholera nostras s. infantum. 
It usually rages in epidemic form during the hot summer months, espe- 
cially among bottle-fed infants and those exposed to bad hygienic con- 
ditions, but occurs sporadically also at other seasons of the year. As 
with other contagious and infectious diseases, previous ill health serves 
as an active and favorable predisposing cause also in this destructive 
affection, the acute and grave symptoms ordinarily supervening upon 
a latent period of indisposition of variable duration. 

The attack ushers in suddenly with vomiting, diarrhea and prostra- 
tion. The vomiting is more or less projectile in character and occurs 
especially immediately after drinking. The evacuations range between 
fifteen to thirty, or more, in twenty-four hours, are at first fecal in 
consistency and odor, but soon turn very watery, serous, light yellow 
or greenish in color, and occasionally are mixed with blood-streaked 
mucus. The abdomen is often trough-shaped and but slightly sensi- 
tive to pressure. The thirst is intense ; the tongue dry, brown or 
black and cracked, irrespective of the degree of temperature, which is 
rarely very high. Owing to the excessive loss of fluids, the urine is 
very scanty and often contains a moderate amount of albumin. 

As the disease progresses the child perceptibly loses in weight, from 
hour to hour; its face is pinched, its fontanelles, temples and eyes 






\ 







_ 



m v>: ~ 




DISEASES OF THE ALIMENTARY TRACT 251 

are deeply sunken; its extremities are cool and blue; the heart beat 
and respiration barely audible — in short, the child is in a state of 
profound collapse. Apathy, somnolence, convulsions and death then 
follow in rapid succession ; the younger the child, the earlier, as a rule, 
the fatal termination. The latter is sometimes preceded by a state of 
hydrocephaloid — a condition variously ascribed to cerebral anemia or 
hyperemia, edema of the meninges and uremia, and presenting the fol- 
lowing symptom-complex : First stage, fever, restlessness, jactitations, and 
insomnia, flushed face, strong and bounding pulse; second stage, sub- 
normal temperature, cold extremities, feeble, irregular pulse and respi- 
ration, apathy, sopor and coma. 

The disease having reached this grave stage, it offers a very bad prog- 
nosis ; few children manage to survive so violent an attack. Some of the 
few who do, are apt to succumb later to complicating nephritis, pneu- 
monia, cerebral sinus thrombosis, peritonitis and the like. 

Convalescence is very tedious even in the absence of complications, 
and a great many children remain decrepit for life ; chronic otitis media, 
xerosis of the cornea and panophthalmia often adding to their share of 
misery. 

With such sad prospects in view after the gastrointestinal affection 
is fully established, the urgency of early and energetic prophylaxis and 
treatment can readily be appreciated. 

Treatment. — To prevent the graver forms of gastroenterocolitis we 
must promptly remove the causes and effects of the mildest symptoms 
of the disease. Attention to every detail of rational feeding and 
personal hygiene and strictest cleanliness of the child's living rooms, 
feeding utensils, wearing apparel, and of all other things coming in 
direct contact with the patient are the surest means of prevention. As 
in the majority of instances, the pathogenic bacteria enter the in- 
fantile alimentary tract with infected milk or water, these should, 
especially in the summer months, be sterilized or even boiled, regard- 
less of the temporary arrest of gain in weight that is concomitant with 
such feeding — a puny baby on the lap, rather than a fat one in the 
grave ! Weaning of the baby and other innovations during the hot 
summer months should be avoided. Lengthy voyages, exacting pro- 
longed disturbance of rest, sleep, and improper feeding should be 
interdicted. On the other hand, a sojourn in the country (inland, 
mountains, or seashore) should be encouraged. Last but not least 
in importance as a prophylactic measure is the practice of whole or 
partial breast feeding of infants under one year of age, unless counter- 
manded by definite contraindications. 



252 DISEASES OF CHILDREN 

The active treatment should begin, as already suggested, with the 
earliest inception of the gastrointestinal disorder. Regulation of diet 
is our most efficient therapeutic measure, and is almost invariably at- 
tended by improvement in the child's condition, if it is begun with a 
few hours' starvation of the patient and prompt cleansing of the ali- 
mentary tract of its obnoxious contents. Feeding, breast or bottle, 
should at once be suspended until such time as exigencies for resump- 
tion of feeding shall demand. In the meantime, especially in the ab- 
sence of strong contraindications, such as violent vomiting, the infant 
should receive small quantities of hot or cold pure water or a light 
infusion of black tea, sweetened with saccharin. Recurrent vomiting 
calls for prompt attention, especially because of its fearfully exhaust- 
ing effects, but also, because it greatly hinders in the administration 
of suitable medication. Ordinarily vomiting can be controlled by "ice- 
sand," minute doses of calomel with large doses (gr. x) of bicarbonate 
of soda; bismuth and cerium oxalate; tincture of iodine (in 1/30 of a 
drop doses, to be repeated every hour or two) ; and, if all else fail, lavage. 
In hospital practice the order of these therapeutic suggestions is usually 
reversed, i. e., lavage is usually resorted to first, and, as a rule, with 
immediate relief to the patient. In private practice, however, one often 
meets with objections on the part of parents, and hence is obliged pri- 
marily to "medicate." Lavage should be supplemented by enteroclysis 
and, with the vomiting checked, also by a small dose of castor oil. 

This mode of treatment generally suffices to arrest gastrointestinal 
affections of moderate severity. "Where the diarrhea persists, we are 
often called upon to administer an astringent mixture like the follow- 
ing : 

I* Bismuthi subcarbonatis, 

Mist, cretse comp., 

Syr. rhei aromat., 

Glycerin., 

Aq. menthae pip aa, 3ij 8.00 

Aq. destil q. s. ad f gij. | 60.00 

M. 
S. — One teaspoonful every two hours for a child one year old. 

The camphorated tincture of opium may be added for the relief of 
pain. After complete cessation of vomiting, we may resume feeding, 
first with small quantities of toast- or barley-water or dextrinized 
gruel (cereo), and several hours later, diluted protein milk (1 ounce 
of the milk with an equal or a larger quantity of water, and later 
cereal water). After the diarrhea has been arrested, the feeding with 



DISEASES OF THE ALIMENTARY TRACT 253 

breast milk or modified cow's milk in small and gradually larger quan- 
tities, may be resumed. 

In fulminating attacks of gastroenterocolitis, where the bacterial 
toxins so violently overwhelm the infantile organism and produce intense 
shock, the treatment must be very prompt and more heroic. In the 
initial, febrile stage, after a single but thorough irrigation of the stom- 
ach and bowels, the little patient is given 1/50 of a grain of morphine 
and 1/500 of a grain of atropine hypodermically, is wrapped in warm 
blankets and sent outdoors — wherever a good breath of air is obtainable 
— preferably to the seashore. After responding favorably, the treatment 
is followed up in the manner previously outlined for less severe cases. 

In the algid stage, where the child is at death's door — wasted, cold, 
blue, rigid and lifeless, in short in profound collapse — powerful stimu- 
lation is in order. Thus, a hot bath with brisk rubbing of the body; a 
hot (110° F.) high enema (injected slowly so as to be retained), hot water 
by mouth, hypodermic administration of sterile camphorated oil (8 
drops of a 15 per cent solution), strychnine (gr. 1/60 to 1/30), caffeine 
sodium benzoate (1 grain), or whiskey (10 drops), hypodermoclysis (1 to 
6 ounces of a 0.9 per cent hot sterile salt solution), and injection of 
normal saline in the peritoneal cavity or longitudinal sinus (see p. 209). 
As the patient improves a milder course of treatment is, of course, re- 
sorted to. The physician should not be deceived, however, by those 
apparent improvements, as they not rarely precede fatal termination. 

II. Subacute and Chronic Gastroenterocolitis 

Exhausted by the paralyzing action of the virulent bacterial toxins ; 
wasted and weakened from the excessive loss of body fluids and the 
strict starvation diet enforced during the acute course of the disease, 
the little patient rarely, if ever, emerges in a state of health capable 
of exercising its digestive organs to their normal capacity. On the 
contrary, convalescence usually proceeds at a very slow pace, and is 
frequently interrupted by milder exhibitions of gastrointestinal in- 
digestion, which, if not promptly yielding to energetic treatment, 
eventually lead to chronic involvement of the alimentary tract. 

The mucosa of the stomach and bowels, especially of the ileum and 
colon, undergoes gradual thickening, and often ulceration. The 
mesenteric glands are more or less enlarged, and on cross-section are 
partly red and partly yellowish gray in color and sometimes caseated. 
In very protracted cases the mucosa and its follicles are atrophied, and 
the lungs, liver and heart are in a state of inflammation and degenera- 
tion. 



254 



DISEASES OF CHILDREN 



The bowel movements continue to be frequent (four or five times in 
twenty-four hours). The stools are thinner than normal, are mixed 
with particles of undigested food, mucus, and blood. The abdomen 
is flat, sometimes deepty sunken, and through its thin and w T asted wall 
one can readily palpate the greatly enlarged, "ropy," mesenteric 
glands. The child's appetite is capricious, often very good, and 
contrasts strongly with the persistent loss of weight. The tongue 
is coated and flabby, its edges are red and indented by the teeth or 




Fig. 59. — Chronic gastroenteritis in an infant ten Tveeks old. (See Fig. 5G.) 



gums, and here and there covered by an aphthous deposit. Slight in- 
discretions in the dietary are promptly followed by vomiting and diar- 
rhea. Chemical examination of the contents of the stomach discloses 
marked diminution of hydrochloric acid. 

The course of chronic gastroenteritis varies in individual cases. 
Some infants, especially those in whom the chronic affection followed 
upon the acute form, who remained free from grave complications and 
retained some vitality, often unexpectedly show marked improvement 



DISEASES OF THE ALIMENTARY TRACT 255 

with the setting in of cooler weather, and regain their health fully 
within a few weeks. 

In another group of cases recovery is less rapid. Improvement al- 
ternates with aggravation of the condition, but, finally, the infant ex- 
tricates itself barely alive, with a load of sequelae {e.g., rachitis) which 
keep it in a state of decrepitude for many months and even years there- 
after. 

In still another group of cases all therapeutic efforts utterly fail 
to effect a cure. The child's face has a pallid, earthy tint, and senile 
expression; the skin is dry and hangs in folds; the fontanelles and 
temples are depressed, and after a period of several weeks or months 
the infant finally succumbs either slowly with symptoms of cerebral 
anemia and heart failure or suddenly during an attack of eclampsia. 
The fatal termination is frequently enhanced by complicating pulmo- 
nary (passive- or bronchopneumonia) and renal (colicystitis, pyelitis, 
etc.) affections; skin (ecthyma, furunculosis), ear and mouth infec- 
tions, or intercurrent acute communicable diseases (exanthemata). 

At best the prognosis is very grave (30 per cent mortality), espe- 
cially so in infants reared under bad hygienic conditions, in want and 
misery, and in those born with lowered vitality and congenital defects. 

However, no effort should be spared to save an infant that is ap- 
parently hopelessly lost, for just in chronic gastroenteritis the unex- 
pected sometimes happens — recovery takes place at a time when re- 
lief by death is prayed for. 

Treatment. — The patient should be removed from insanitary sur- 
roundings and intrusted to the care of some one who will obey orders 
rather than use her own judgment and that of the many "good and ex- 
perienced" neighbors. Be it remembered, that only too often change 
of nurse (with her gross negligence and stubborn interference) has 
saved many a hapless baby ! Regulation of diet is most essential. Xo 
hard and fast rule, however, can be laid down in this direction. "We must 
feel our way in every individual case. It is always a good plan in bot- 
tle-fed babies to begin treatment with discontinuance of the milk for a 
day or two and thorough cleansing of the alimentary tract by a laxative, 
lavage and enteroclysis. In the meantime the patient should be fed 
on thin barley water, acorn cocoa, a light infusion of black tea, albu- 
min water, diluted protein milk, and perhaps, a small quantity of freshly 
boiled, fat-free chicken or mutton soup. As soon as the stools diminish 
in frequency and improve in consistency, we resume milk feeding in 
very high dilution. For a child, let us say of six months, one table- 
spoonful of fat-free milk to seven tablespoonfuls of barley or rice water, 



256 DISEASES OF CHILDREN 

to be given every three hours, may be prescribed, and directions given 
daily to increase the quantity of milk until the percentage of 1 to 2 has 
been reached ; then gradually the total quantity at the last ratio (i. e., 
1 to 2) is augmented, until 6 ounces are obtained for each feeding. 
Should the milk mixture disagree, a weaker milk mixture is resorted 
to, or milk is again discontinued, falling back upon albumin milk with 
cereals, albumin water and tea. Some infants do well, at least for a 
time, on condensed milk and barley water; others, especially those suf- 
fering from the so-called "fat-diarrhea," improve rapidly on albumin 
milk, skimmed milk or whey, and still others (older ones), who cannot 
tolerate milk in any form, get along on toast and tea, acorn cocoa in 
water, mashed potato with beef juice or chicken soup, soft-boiled egg, 
ground rice custards and similar semisolid articles of food. In a great 
many instances "malt soup," prepared in accordance with the directions 
of Keller, acts admirably, both as a tissue builder and to check the pro- 
tracted diarrhea. Last in line, but foremost in importance, is the fact 
that in young infants a complete cure of chronic gastroenteritis in bot- 
tle-fed infants is effected by a prompt change from bottle to breast feed- 
ing. 

The medicinal treatment of chronic gastroenteritis is chiefly symp- 
tomatic. When vomiting persists, lavage (with warm boric acid solu- 
tions) should be practiced daily or every alternate day, and, if need 
be, continued for a few weeks. Digestion may be aided by means of 
pancreatin and diastase, and the appetite improved by small doses of 
tincture nux vomica and dilute hydrochloric acid and pepsin. The 
patient should be given daily a low intestinal irrigation, either with 
one quart of plain hot (110° F.) water, 2 per cent of bicarbonate of 
soda, or, where the lesion is localized principally in the lower bowel — 
as indicated by predominance of blood and mucus in the evacuations — 
with 1/10 per cent solution of nitrate of silver. Where the diarrhea 
persists notwithstanding progressive improvement in the general con- 
dition of the patient, the newer tannin preparations (e.g., tannalbin, 
tannigen) are very serviceable. The tannates may be combined with 
some bismuth preparation (e. g., subgallate of bismuth, 2 to 4 grains), to 
enhance the astringent effects, and small doses of Dover's powder (% 
grain every three hours) to arrest active peristalsis. 

Change of air (seashore), strict cleanliness of the body, change of 
position and frequent picking up of the patient from its bed, and ac- 
tive stimulation (strychnine, cinchona, Tokay wine and champaign) are 
active preventives of serious complications. 



DISEASES OF THE ALIMENTARY TRACT 257 

Dysentery, Enterocolitis, Ileocolitis, (See page 412) 

Acidosis (See p. 522.) 

Proctitis 

Inflammation of the rectum is usually secondary in character and not 
rarely associated with gastroenterocolitis, dysentery, oxyurides, and 
prolapsus recti, and less frequently with gonorrhea (vulvovaginitis, 
(q.v.) and diphtheria. Occasionally it is the result of trauma (e. g., for- 
eign body), and the effect of drastic cathartics. 

The principal symptoms of this affection consist of tenesmus (some- 
times also strangury), frequent discharge of blood, mucus, and pus, 
with little fecal matter, and more or less severe colic. Depending upon 
the primary cause of the disease, the discharges may contain different 
kinds of bacteria {e.g., ameba, gonococcus, diphtheria bacillus; worms, 
etc.), a fact which should always be borne in mind before arriving 
at a diagnosis and resorting to treatment. Proctitis should not be con- 
founded with rectal fistula, polypus or hemorrhoids, purpura hemor- 
rhagica and intussusception. The treatment depends upon the underly- 
ing cause; in the main resembling that of dysentery (q.v.). 

Colica Infantum, Gastralgia, Enteralgia, Neuralgia Enterica 

Infantile colic is usually associated with a number of congenital 
(gastrointestinal stenosis, etc.) and acquired (gastrointestinal inflam- 
mations, etc.) diseases of the alimentary tract. Less frequently it is 
apparently free from organic underlying causes. This so-called "idio- 
pathic" form of colic is a spasmodic affection of the intestinal muscula- 
ture, the result of pathologic irritations which act by way of the periph- 
eral cutaneous nerves or the sensory intestinal nerves. To avoid 
unnecessary repetition, it may briefly be stated that anything capable of 
producing gastrointestinal disturbance may form the cause also of the 
said pathologic irritations. This occurs especially in premature in- 
fants and in those whose digestive organs are not quite fully developed. 

Some babies, breast or bottle fed, begin to suffer from colic soon 
after birth, and do what you will, maintain their "record" for several 
months, — until, with gradual growth, the digestive organs attain their 
normal functions. Such "colic-babies," if reared without immediate 
strict supervision of a capable nurse or physician are apt very soon to 
contract a severe gastrointestinal disorder from the effect of the ex- 
perimental efforts, in feeding and medication, on the part of all who 
sympathize with the "innocent babe." This habitual colic, which is 
manifested by continued fretfulness, sleeplessness, and pseudobulimia 



258 DISEASES OF CHILDREN 

(instinctive, eager desire for warm drinks which temporarily relieve the 
pain), is to be distinguished from acute intestinal colic (colica flatulenta), 
which is sudden in development and rapid in disappearance, the latter 
depending upon the time required to get rid of the gas or stool. During 
a severe attack of acute colic the child's face is spasmodically drawn and 
bathed in perspiration. The patient refuses food, cries pitifully, and 
draws its legs upon the abdomen. The spasm sometimes extends to the 
other muscles of the body, leading to general convulsions, and excep- 
tionalty even to coma and fatal issue. Of course, in the majority of in- 
stances, the termination is favorable, especially under prompt and ap- 
propriate treatment. 

Treatment. — In breast-fed infants attention to the health of the 
mother or wet-nurse — avoidance of excitement, regulation of the bow- 
els, indulgence in outdoor exercise — and in both breast and artificially 
fed, prevention of constipation and overfeeding of the infant, more 
particularly with fat mixtures, are very efficient anticolic measures. 
Where repeated examination of the breast milk proves it to be too 
rich in fat or protein, the infant should be given a few T teaspoonfuls 
of water or of some other diluent immediately before each nursing, 
and the length of time for each nursing proportionately reduced. 

As long as the infant thrives, notwithstanding the colic, no very 
material changes in the feeding should be attempted, as too much 
experimenting often makes matters worse. 

In habitual as well as flatulent colic, heat, either in the ~f orm of 
fomentations (a few drops of turpentine in a quart of warm water), 
gentle massage of the abdomen with warm oil, or warm drinks such 
as chamomile, fennel seed or peppermint tea, will be found to act well. 
In cases of acute colic this must be preceded by a warm water enema 
to aid in the expulsion of the gas or stool. Of drugs, the following prep- 
arations are worth trying: 

Charcoal and magnesia, of each 1 or 2 grains one hour after feeding ; 
mistura sodae et menthaa, N. F., 5 to 10 drops every ten minutes until 
relieved; compound spirits of ether, sweet spirits of nitre, or cam- 
phorated tincture of opium in doses of from 2 to 5 drops, to be re- 
peated two or three times. In purely nervous colic asafetida often 
acts magically. The lac asafetida (% dram to 1 pint of warm water) 
should be gently administered by rectum. The ammoniated tincture 
of Valeria (5 drops) and sodium bromide (2 grains) are often equally 
efficient. As to the treatment of convulsions, see p. 670. 

Proper food, regular bowel movements, and fresh air are efficient 
prophylactic measures. 



DISEASES OF THE ALIMENTARY TRACT 259 

Infantile colic should not be confounded with intestinal intussus- 
ception, appendicitis, and biliary, renal (uric acid infarct!), or vesical 
calculi. 

Chronic Constipation 

Judging by the construction of the infantile intestines — their great 
length, the thinness and feebleness of their musculature, etc. — nature 
seems to have intended that infants as well as older children should be 
more or less constipated. Indeed, the popular belief that healthy 
children are usually constipated, is often corroborated by actual ob- 
servation. Xot infrequently, however, obstinate constipation gives 
rise to a number of disagreeable symptoms (flatulence, anorexia, head- 
ache, restlessness, sometimes convulsions ; anemia, toxemia, a tendency 
to renal irritation, possibly with colicystitis ; proctitis, anal fissure, pro- 
lapse of the rectum, hemorrhoids, etc.) requiring active treatment, a 
task often difficult to cope with in view of the uncertainty of the 
etiologic factor of the underlying disease. 

The causes of habitual constipation are very numerous. Aside from 
the cases resulting from gross abnormal anatomic relations or diseases, 
such as the different varieties of atresia intestini, recti, or ani; tumors; 
congenital dilatation with hypertrophy of the colon; hypertrophy of 
the valvule conniventes ; hypertrophy of the so-called rectal valve ; in- 
flammatory adhesions; congenital displacements — which will not be 
discussed here — constipation is ordinarily caused by faulty diet, atony 
of the bowels, and constitutional disturbances. 

Faulty diet is responsible for a great many cases of constipation. 
This etiologic factor is frequently potent also in infants, when the 
woman's milk contains too much or too little of one or more of the 
constituents of milk, or when it is insufficient in quantity. In arti- 
ficially fed infants the cause of the constipation will probably be found 
in the excess of fat consumed. In some children constipation is due, 
on the one hand, to too early and persistent feeding with amylaceous 
food. and. on the other hand, to the consumption of food that does not 
stimulate peristalsis, such as an exclusive diet of milk, meat, eggs, 
etc., and no fruit, potatoes, bread, fresh vegetables, etc. 

Atony of the intestines may be primary, congenital in nature, or 
secondary or acquired. The former variety can frequently be traced 
as an hereditary taint through several generations. Sometimes there 
is, in addition to the muscular insufficiency, also congenital weakness 
of the innervation of the intestines. The latter condition embraces also 
the form of atony usually associated with congenital diseases of the brain 
and spinal cord. Secondary or acquired intestinal atony is generally 



260 DISEASES OF CHILDREN 

the result of repeated attacks of temporal constipation, gastrointes- 
tinal indigestion with fermentation, entcrospasm, arrest of peristalsis 
due to reflex irritation of the inhibitory nerves of the intestines, acute 
inflammatory processes of the intestinal canal with consecutive atro- 
phy of the intestinal coats, constriction of the lumen of the bowels by 
temporary displacements (enteroptosis, hernia, etc.), habitual sup- 
pression of defecation or attention to it at irregular hours, enemas 
with large quantities of fluids, etc. All these etiologic factors produce 
intestinal atony by directly or indirectly distending the lumen of the 
bowels and depriving the intestinal musculature of its resilience and 
tonicity. 

In different chronic diseases associated with general debility {e.g., 
rachitis) and loss of flesh; in diseases of the nervous system, such as in- 
fantile paralysis, myelitis, meningitis, etc., the sluggishness of the bowels 
forms merely a symptom of the principal disease. Habitual constipa- 
tion is often met with in diseases of the heart, profound anemia, etc., 
as a result of venous stasis of the abdominal organs. To the same cause 
is attributable also the constipation occurring in children who, through 
deformity or when otherwise afflicted, are incapacitated to enjoy a suffi- 
cient amount of bodily exercise. 

The treatment of obstinate constipation in infancy and childhood re- 
solves itself, first, in arresting the causes instrumental in the production 
of the disease ; secondly, in the removal of the damage done during the 
continuance of the constipation — not quite as easy a task as some authors 
wish us to believe. Indeed, numbers of cases of chronic constipation 
are never cured, no matter what therapeutic means are being employed. 
Preventive measures are, therefore, to be recommended early and carried 
out with precision. 

It is of primary importance to train the child to have a movement reg- 
ularly every day. Proper habits are often easily formed if the child is 
put upon the chamber or chair invariably at the same hour. The first 
few days it may equire local stimulation to defecation (e.g., introduc- 
tion into the rectum of a small oiled syringe tip). Similar means should 
be employed also with older children; particularly, with school children 
who are very apt to suppress Nature's impulse to empty the bowels. 

Two main factors are instrumental in the expulsion of the rectal con- 
tents: contraction of the abdominal muscles and the diaphragm, and 
separation or relaxation of the gluteal group of muscles. If the seat 
of the commode is too high and the aperture in the seat too wide no sup- 
port is given to the tubera ischii, the gluteal muscles are crowded to- 
gether instead of separated, and the descent of the floor of the perineum 
is much hindered. This impediment to defecation may be obviated by 



DISEASES OF THE ALIMENTARY TRACT 261 

substituting a low seat on a nursery chair or toilet, or small vessel 
for the high one previously used. The child is thus enabled to accom- 
plish this act in a squatting posture, which is most favorable to thor- 
ough emptying of the rectum. 

Correction of diet is, of course, very valuable for the prevention of 
habitual constipation, but does not always remedy the trouble. This is 
particularly true of cases of very long standing, since here we are 
dealing with secondary atony following prolonged distention and enfee- 
blement of the intestines. The diet should vary, of course, with the 
age of the patient and consistency of the stools. As a rule, the latter are 
either small, hard and marble-like, or very large, acholic, and sausage 
shaped. In the first case, the dietary should be improved by the addi- 
tion of fat and cereal gruels, such as groats and oatmeal. In the second 
case, good results are often obtained by reducing the cereals and fats 
and by substituting malt cereals. In older children a moderate supply 
of cream, malt extract, honey, rye bread, bran, raw or cooked fruit, and 
vegetables may remove the difficulty. A glass of cold water on an empty 
stomach, and at night before retiring, is often very useful. 

Faithful compliance with the suggestions just made very often yields 
favorable results. In a certain percentage of cases, however, more active 
measures have to be resorted to and it then devolves upon the physician 
to select such therapeutic means as will not effect the general wellbe- 
ing of the patient. In older children, this indication can most appro- 
priately be met by the simultaneous employment of a combination of the 
so-called physicochemic procedures, consisting of massage, oil enemas and 
hydrotherapy, and occasionally, also electricitj^. This treatment is more 
advantageously carried out in the evening, before the patient goes to 
sleep. The child is placed on a hard couch or mattress with head and 
thorax raised and legs sharply flexed at the knee- joints and somewhat 
rotated outward. The attendant stands on the left side of the patient. 
The manipulations are begun at the fossa iliaca sinistra, where the sigmoid 
flexure is situated and is frequently found to be a halting place for 
hardened feces. With the tips of the fingers of one hand (in older chil- 
dren both hands may be used, one hand being placed upon the other), 
the attendant makes gentle circular movements along this portion of the 
colon and at the same time exerts upon it considerable pressure downward 
toward the rectum. Without changing these movements the attendant 
slowly ascends as far as the splenic flexure. From here he gradually 
returns to the sigmoid. He now begins a new tour, going as far as the 
hepatic flexure, and after gradually returning to the starting point he 
makes his final trip, reaching the cecum and, in the manner just outlined, 
returns again to the fossa iliaca sinistra. These manipulations should 



262 DISEASES OF CHILDREN 

be followed by rhythmical vibratory strokes over the entire abdomen, in- 
terrupted b}^ a few pressure movements against the spinal column in 
the epigastric region. The treatment should last from six to twelve 
minutes. 

Instead of trying the massage, oil enemas, and hydrotherapy sepa- 
rately, it is certainly preferable to employ these three procedures — the 
anticostive triad — simultaneously, since they do not interfere with one 
another, but, on the contrary, supplement one another in their beneficial 
effect. Thus, after completing the massage, the little patient is turned 
upon his left side, and by means of a piston syringe, V2 ounce or more of 
warm oil is gently injected into the rectum and allowed to remain there. 
This is followed by the application around the abdomen of a Priessnitz 
compress, which should be left in place until the next morning. It will 
almost invariably be found that the patient's bowels will act either 
during or soon after the treatment, or at any rate, not later than the 
following morning. A three or four weeks' course of treatment will 
usually suffice to establish regularity of the bowels, provided the preven- 
tive measures suggested before are strictly adhered to. In some very 
protracted cases of constipation these procedures may be supplemented 
by the application of the galvanic or faradic current. One electrode is 
passed successively over different portions of the abdominal wall, and the 
other electrode is placed upon any other part of the body. 

Proctologists frequently advocate divulsion of the sphincter ani as a 
sure cure of habitual constipation. I am not inclined to be quite as 
enthusiastic over it, except in cases of constipation due to rectal disease, 
as, for example, fissura ani, rectospasmus, etc. 

Finally, there is a class of cases of chronic constipation which resists 
all forms of treatment as regards a permanent cure, but may be con- 
siderably improved by alternately resorting to the therapeutic measures 
already enumerated as well as to drugs. In the selection of an evacuant 
the physician must be guided by the etiologic factors and the individual 
peculiarities of the case in question. The indiscriminate use of anti- 
spasmodics (belladonna) as well as the ever-ready "soothing" laxatives, 
is to be strongly deprecated. Of all the laxatives in use, mineral oil 
is the safest and most efficient. In a child five or six years old, we begin 
with a tablespoonful once a day and, as regular evacuation is established, 
we gradually reduce the dose. Temporarily effective and comparatively 
harmless are also the following remedies: Soap and glygerine supposi- 
tories, medicated cocoa butter suppositories (with aloin and belladonna 
in spastic, or aloin and nux vomica in atonic, constipation), enemas with 
small quantities of glycerine or larger quantities of soap water; inter- 
nally, magnesia usta, magnesia and rhubarb, compound licorice powder, 



DISEASES OF THE ALIMENTARY TRACT 



263 



castor oil, extract of cascara sagrada, calomel followed by a mild saline 
aperient, and, in older children, the standard mineral salts or waters. 

Whatever the method of treatment employed, the establishment of a 
habit to move the bowels regularly at a certain time of the day should 
at all times be our chief aim. 

Prolapsus Ani, Prolapsus Recti 

If the prolapse is limited to the mucous membrane of the anus, the 
condition is spoken of as prolapsus ani; if the lower portion of the 




Fig. 60. — Prolapsus recti. 

rectum protrudes through the anal orifice, it is known as prolapsus 
recti. In prolapsus recti the protruding part comes down during def- 
ecation in the form of a round, or sausage-shaped, glistening, red 
or bluish red, frequently bleeding mass. In the beginning, the mucous 
membrane slips back in its place spontaneously, or is easily replace- 
able and remains there until the next movement ; in severe cases, owing; 



264 DISEASES OF CHILDREN 

to marked inflammatory thickening:, reposition of the mass may be 
difficult, and if replaced, may immediately prolapse again. 

These conditions are very common in young children, the softness 
of the connective tissue and incomplete development of the muscular 
S} 7 stem serving as predisposing causes. The ordinary exciting causes 
are habitual constipation, protracted diarrhea, proctitis, rectal poly- 
pus, oxyuris, phimosis, vesical calculus, i. c, conditions in which the 
act of defecation or urination is attended by pressing, tenesmus, or stran- 
gury. Protracted, paroxysmal coughing {e.g., pertussis), by its down- 
ward pressure upon the abdominal contents, also serves as an etiologic 
factor, and prolapsus recti is not infrequently associated with rachitis, 
probably due to the accompanying muscular debility and constipation. 

The diagnosis can readily be made by inspection and digital examina- 
tion. It is most apt to be confounded with hemorrhoids and rectal poly- 
pus. Rectal polypus is the most frequent cause of rectal bleeding in 
children, and appears at the anus as a dark-red, bean- to cherry-sized, 
roundish tumor with a bleeding surface. Digital examination usually 
reveals that the polyp is attached to the rectum, a few centimeters above 
the sphincter, by means of a short or long pedicle. 

Slight prolapse is readily amenable to reposition of the prolapsed 
mass (oiling and gentle pressure upward with the patient in the knee- 
chest position) and strapping of the buttocks (in older children only 
before the act of defecation), in addition to prompt attention to the 
aforementioned etiologic factors. Severer cases call also for reduction 
of the local inflammation by occasional painting of the affected area 
with balsam of Peru or a 2 to 5 per cent solution of nitrate of silver. 
If these measures fail, the prolapsed mass may have to be treated by 
punctate or linear cauterization. However, the possibility of subsequent 
anal stricture, should be kept in mind. 

General tonic treatment not rarely succeeds when local procedures fail. 

Intussusception 

(Intestinal Invagination) 

Intussusception, or sliding of one portion of the intestines into the 
other, is an affection principally of infancy and early childhood. The 
commonest seat of the trouble is the ileocecal region. Thus, the proxi- 
mal portion of the ileum with or without the cecum becomes invagi- 
nated into the colon. Less frequently the ileum slides into the ileum, 
or a part of the colon into the colon. Occasionally the invagination is 
multiple and is responsible for the so-called recurrent intussusception (A. 
Sturmdorf). The immediate results of the invagination are agglutina- 



DISEASES OF THE ALIMENTARY TRACT 265 

tion of the opposed serous layers and strangulation of the impacted 
portion of the intestine. If the latter is not soon relieved, gangrene, 
sloughing and, in a few days, spontaneous discharge of the cast-off 
piece of intestine occurs — the continuity of the intestine being preserved 
by end-to-end adhesion. 

The disease sets in very suddenly. In the midst of apparently perfect 
health, or preceded by diarrhea and colic, the child suddenly shrieks 
from intense pain and presents other symptoms of severe colic which 
fail to yield to ordinary anticolic therapeutic measures. The pain and 
restlessness increase, the abdomen, which at first may be normal or even 
retracted, scon becomes greatly distended, and, accompanied by marked 
tenesmus, the child passes from the bowels at first small quantities of 
feces mixed with mucus and blood, and later pure blood, often of a cadav- 
eric odor. 

Digital examination discloses blood in the rectum — often long before 
any is passed with the stools — and if the intussusception is colonic in 
form, frequently a round mass is observed high up in the rectum. Ex- 
ceptionally and late the tumor protrudes from the anus. In ileocecal in- 
tussusception, inspection and palpation reveal a round "lump" or sau- 
sage-shaped mass in the right iliac region, and occasionally a depression 
below the tumor — owing to displacement of the cecum. The tumor is 
less pronounced in intussusception of other portions of the intestines, 
and in some cases can only be detected under anesthesia. 

The severity of the onset is no criterion as to the further course of the 
disease. In a small number of cases the colic suddenly ceases, the child 
resumes its normal appearance, and exhausted from the agonizing pain, 
falls into a profound sleep, waking up apparently well — spontaneous 
improvement or recovery by spontaneous reduction of the invagina- 
tion has apparently occurred. In such a cure the trouble is not al- 
ways at an end, for the intussusception is very apt to return after 
a shorter or longer interval. In another group of cases, after the 
grave onset, the disease may pursue a milder course. The vomiting, 
meteorism, and tenesmus abate in their A T iolence; the dejecta lose their 
bloody consistency, and the colicky pain returns only after long 
pauses. After three to six days, a piece of gangrenous intestine, the in- 
tussuscepted portion, may be discharged per rectum. This process is 
always fraught with danger, the greater number of these patients 
dying from general sepsis. The few patients who survive frequently 
succumb to consecutive chronic gastrointestinal catarrh, with or with- 
out intestinal stricture. In the majority of instances, the symptoms 
grow worse within twenty-four hours from the start of the attack. 
The vomiting becomes violent and stercoraceous, the pulse feeble, the 



2GG 



DISEASES OF CHILDREN 



extremities cold, the expression of the face pinched, the eyes sunken, 
and, unless the condition is promptly relieved, the child succumbs 
within from four to eight days to increasing collapse, not rarely pre- 
ceded by intestinal perforation and peritonitis. 




Fig. 61. — Stick pin in transverse colon giving rise to symptoms of intussusception 

requiring operation. 



At all events the prognosis is very grave. The mortality ranges 
between from 50 per cent and 80 per cent in cases left alone or treated 
palliatively. On the other hand, with prompt surgical treatment, the 
chances for recovery are by far better — about 65 per cent. The best 



DISEASES OF THE ALIMENTARY TRACT 



267 



results (75 per cent) are obtained in cases operated upon within twen- 
ty-four hours of the onset of the attack. 

The treatment of choice, therefore, is obvious. Early operative in- 
terference, — before extensive adhesions and gangrene of the bowels 
have taken place. Temporizing is fatal. However, before an opera- 
tion is resorted to, we must be quite certain that we are not dealing 
with acute peritonitis, appendicitis or intestinal obstruction from 
other causes — with which diseases intussusception is most apt to be 
confounded. 

Differential Diagnosis 



CHARACTERIS- 


INTUSSUSCEP- 


ACUTE AP- 


ACUTE PERI- 


STRANGULA- 


TIC SYMPTOMS 


TION 


PENDICITIS 


TONITIS 


TION 


Onset 


Sudden 


Variable 


Variable 


Sudden 


Tumefaction, 


Most frequently 


McBurney 's 


Distributed 


Local disten- 


its seat and 


ileocecal re- 


point. Eig- 


throughout 


tion of bowel. 


nature 


gion, occa- 


idity of ab- 


abdomen, al- 


Chiefly at ab- 




sionally 


dominal wall 


so local exu- 


dominal 




round tumor 




dation 


rings 




in rectum 








Tympanites . . . 


Moderate 


Absent, at first 


Pronounced 


Slight 


Abdominal 










pain 


Intense, general 


Moderate, local 


Marked, gen- 
eral 


Severe, gen- 
eral 


Constipation . . 


Late, preceded 
by frequent 
muco- 
hemorrhagic 

stools 


Early 


Late 


Early 


Fever 


Slight 


High 


High 


Slight 


Collapse 


Early 


Late 


Early 


Early 



When the services of a competent surgeon are not obtainable, an 
attempt may be made to reduce the invagination by copious injections 
of warm (100° F.) water into the bowels, or by air inflation. 

For the water injections an ordinary fountain syringe with a rectal 
tube, suspended about 4 feet above the level of the patient's pelvis, 
answers the purpose. Two to 4 quarts of water should be used. Dur- 
ing this procedure the patient should be kept on his back with his 
buttocks raised about 1 foot above the level of the shoulders. Occa- 
sional inversion of the child, or the Trendelenburg position under anes- 
thesia is useful. 

For the relief of pain and arrest of undue peristalsis, morphine and 
atropine hypodermically ; to check vomiting, lavage; to combat col- 



268 DISEASES OF CHILDREN 

lapse, stimulants and external heat. Liquid food that is easily di- 
gestible should be given to sustain nutrition. Complications arising, 
should be treated according to indications. 

In view of the obscure causes of this affection, very little can be 
accomplished in the way of prophylaxis. Avoidance of habitual con- 
stipation, of drastic purgatives, and of violent exercise (rapid up-and- 
down motion) may prove efficient prophylactic measures. Occasion- 
ally, intussusception follows typhoid fever, Meckel's diverticulum and 
severe adhesions secondary to appendectomy. The relationship be- 
tween invagination and polypoid intestinal growths still lacks authori- 
tative confirmation. 

Case Report. — As is usual in acute intussusception, the five-months-old infant un- 
der my observation -was suddenly seized with pain and vomiting, became very 
restless and refused to take the breast on which she had been nursed from birth 
on. As the mother of the baby had at the time been greatly worried over the fate 
of her husband, who was undergoing an operation for strangulated hernia, she 
attributed the unexpected illness of her child to some "nervous" disturbance of 
her breast milk. Moreover, on a few occasions the baby had also received a bot- 
tle or two of diluted cows' milk, which she thought might have upset her stomach. 
In addition to this the baby three days before rolled out of its go-cart, head down- 
wards, although apparently without any noticeable bad after-effects. A physician 
was sent for the same day, and finding the baby suffering from colic, diarrhea and 
vomiting, ordered a teaspoonful of castor oil, and a rectal irrigation, to be fol- 
lowed a few hours' later by small doses of salol and bismuth. The next day the 
stools assumed a bloody consistency, and presuming that dysentery was dealt with, 
he added a few doses of Dover's powder. The opium seemed to relieve the colic, 
but the bloody stools continued. Alarmed over this condition the family physician 
kindly invited me to see the case with him. This was about three days after the 
onset of the vomiting. The patient was drowsy, and its facial features were 
greatly depressed. Her temperature was 100° F., the pulse slow and feeble, and 
she seemed entirely free from pain. Her abdomen was slightly distended but on 
palpation I readily detected an oval-shaped doughy mass in the left iliac region 
which was very sensitive to pressure. Furthermore, on introducing the finger into 
the rectum, about two ounces of bloody fluid was forcibly expelled from the rec- 
tum along the sides of the examining finger. There could be no doubt as to the 
diagnosis. The sudden onset, the persistent vomiting (which by the way was not 
feculent ! ) , the bloody discharge free from feces, the intense colic and above all, 
the painful mass in the left iliac region, were pathognomonic of intussusception. 
Dysentery was a plausible diagnosis the first day, but surely not thereafter, when 
free blood made its appearance. In some cases intussusception may be mistaken 
for incipient appendicitis, impaction, peritonitis or strangulation, but in none of 
these cases would we find serosanguinolent and later purely bloody stools. Besides, 
these diseases have pathognomonic symptoms of their own, which must always be 
considered in the differential diagnosis. I suggested an immediate operation, and 
Dr. Lilienthal performed the same within an hour. The laparotomy revealed a 
colonic invagination at the sigmoid flexure, embracing the entire colon including the 
cecum. The baby succumbed a few hours later. 



DISEASES OF THE ALIMENTARY TRACT 269 

Appendicitis, Typhlitis, Perityphlitis 

Until recently the prevalence of appendicitis in early childhood was 
not taken very seriously by the profession at large, and hence, either 
because of its skepticism, or for want of understanding of the pathol- 
ogy of the disease, a great many cases of acute or chronic appendicitis 
were either overlooked, erroneously diagnosed or ascribed to "food 
fever," "cyclic vomiting," and the like. Nowadays, the occurrence 
of appendicitis in children and even in sucklings is no longer doubted. 
On the contrary, in view of the frequency with which the vermiform 
process is found implicated in the course of severe infantile gastroin- 
testinal disease, and its tendency by its relatively greater length and 
width to favor lodgment of foreign bodies (such as fecal concretions, 
worms, etc., which act as sources of infection), there is ample reason 
for the belief that as a whole appendicitis is as common in children 
as in adults. As in the latter the severity of the disease in infants varies 
from simple inflammation to fatal gangrene, depending of course upon 
the type and virulence of the causative bacteria and the promptness 
with which it is discovered and treated. 

Pathologically the simplest form of appendicitis consists of a catar- 
rhal inflammation of the appendix. Its mucosa, and follicles are red- 
dened and swollen, and their secretion is more abundant than normal. 
The lymphatics of the walls and of the surrounding structures are 
congested. Gradually the submucous and serous layers become in- 
volved and the appendicular lumen narrowed. In mild cases the ob- 
struction in the appendix subsides, allowing the escape of the mucous 
and bacterial contents, and, with the exception of slight thickening 
and adhesions, rapid restitutio ad integrum takes place. 

In more severe cases the obstruction continues, the appendix becomes 
more and more distended, the mucous secretion purulent, the muscular 
coat, owing to its effort to expel the appendicular contents, thicker, 
hypertrophied, while the mucous membrane, as a result of pressure from 
within the appendix, undergoes gradual atrophy and ulceration. Even 
in this stage of the disease spontaneous recovery by encapsulation and 
absorption of the abscess is still possible. 

In the majority of instances, however, instead of being absorbed, the 
purulent content of the appendix gradually, or rapidly, increases in 
quantity, and finally perforates the overdistended, more or less ulcerated 
appendix. The escaping pus finds its way where there is least resistance 
— into the cecum, small intestine, rectum, urinary bladder, gall bladder, 
diaphragm or into the free peritoneal cavity. The pus may, on rare 
occasions, also penetrate into the retroperitoneal cavity, or externally, 
usually in the right iliac region. 



270 DISEASES OF CHILDREN 

Sometimes the inflammation is almost from the start so intense that 
perforation and gangrene of the appendix, and escape of its virulent 
contents into the peritoneal cavity occur before a diagnosis can at all 
be arrived at. In these cases it is not rare to find also old inflammatory 
adhesions, indicating that the patient had once before gone through an 
attack of appendicitis (recurrent appendicitis), which probably was 
mild and had escaped attention. 

The great variability in the course and termination of the aforemen- 
tioned pathologic process can readily be explained primarily by the dif- 
ference in the virulence of the causal bacteria, no single type of which 
having thus far proved to be the specific etiologic factor of appendicitis 
as a whole or of any of its forms. The bacteria found in the inflam- 
matory products of the disease are principally streptococci, staphy- 
lococci, B. coli communis, the pneumococcus, B. influenza?, etc. It is 
not at all uncommon for appendicitis to develop in connection with 
pneumonia, influenza, gastroenterocolitis, etc., thus tending to prove 
its infectious character. Prominent etiologic factors also are retention 
of fecal concretions, foreign bodies (pins, fish bones, cherry stones, 
orange pits), intestinal worms, traumatism, exposure to cold and wet, 
etc. In a baby eighteen months old, who was operated upon for in- 
guinal hernia, we found seven pinworms and two caraway seeds in a 
perfectly normal appendix. Male children (possibly because more often 
exposed to traumatism) are more frequently attacked by appendicitis 
than female children. Constipation and dyspepsia serve as predispos- 
ing causes. 

Acute appendicitis may set in very suddenly or be preceded by pre- 
monitory signs, consisting of frequently recurring attacks of dyspepsia, 
with colic and constipation. It is quite probable, however, that the dys- 
peptic symptoms are in reality the manifestations of recurrent catarrhal 
appendicitis of very mild type. The appendicitis once established, the 
little patient stops eating, is nauseated, vomits, and cries because of 
pain in the abdomen. The latter is more or less rigid. The anorexia 
is usually complete, and, if the child is forced to eat, the food is sooner 
or later ejected. Infants may continue taking the bottle or breast, to 
quench thirst. In very mild cases, nausea may replace the vomiting, 
but the latter symptom is always present in moderately severe cases 
and is quite severe in grave appendicular involvement, especially when 
the peritoneum is implicated. Pain, spontaneous and on pressure, is 
invariably present during an attack, but it varies greatly in severity 
irrespective of the pathologic condition of the appendix. Sudden ces- 
sation of pain often signifies mortification of the underlying structures, 
and, hence, is to be looked upon as a bad omen. Young children are usu- 



DISEASES OF THE ALIMENTARY TRACT 271 

ally unable to localize the seat of the pain tliey are suffering from; 
little reliance, therefore, should be placed upon its localization. On 
the other hand, pressure pain can readily be elicited, which, as a rule, 
is most intense over the region of the appendix, and which in children 
does not always correspond with "McBurney's point" — the appendix 
is often situated either higher up or lower down in the pelvis. Some- 
times, even infants indicate the presence of pressure pain by attempt- 
ing unconsciously to ward off the examining hand, by placing their 
little hands over the most painful spot. Rigidity of the abdominal wall 
forms a pathognomonic sign of the disease, and proves of great help 
in the diagnosis of appendicitis to one familiar with the peculiar sense 
of resistance of the abdominal wall to pressure. As a rule, the abdomen 
is distended, but it may also be contracted and as hard as a board. On 
gentle palpation the rigidity yields sufficiently to permit the detection 
of tumefaction — the underlying thickened appendix in catarrhal ap- 
pendicitis, or the variously sized, hard or doughy, immovable mass in 
appendicular abscess. In rare cases the tumefaction may be seen to 
project beyond the normal level of the skin, or be felt in the rectum; 
a digital examination, therefore, should never be omitted. As a rule, the 
patient suffers pain when his right leg is extended forcibly, and in 
walking he usually " favors" this leg and often puts the right hand upon 
the abdomen to prevent shaking of the underlying structures. Appendi- 
citis is ordinarily associated with complete constipation ; the attack may, 
however, be ushered in by diarrhea, or, rather, pseudodiarrhea, since the 
stool is derived chiefly from the lower part of the colon, superinduced 
by the sudden irritation within and about the appendix. As the dis- 
ease advances, in consequence of pressure by the growing tumefaction in 
the pelvis, there may be severe tenesmus (as well as strangury) with or 
without a bloody discharge, — a symptom which is very apt to mask the 
diagnosis. The temperature is moderate, from 101° F. to 103° F. in 
catarrhal appendicitis, and as high as 105° F. in abscess formation. In 
favorable cases the pulse and respiration agree with the rise or fall of 
the fever. Low temperature with a high, feeble pulse and complete 
cessation of pain are considered a bad omen, an indication of profound 
sepsis or perforation of abscess. 

Diagnosis. — Cases presenting the aforementioned typical symptoms 
of appendicitis can be diagnosed as readily in the child as in the adult. 
In fact, owing to the thinness of the infantile abdominal wall, and the 
proportionately large size of the appendix, it is usually not difficult 
to palpate an inflamed appendix unless it be — as it sometimes hap- 
pens — misplaced somewhere beyond the reach of palpation. On the 
other hand, there is often considerable difficulty to differentiate an 



2/2 DISEASES OF CHILDREN 

appendicitis pursuing a very violent course with marked tympanites, 
shock and collapse, from a grave attack of acute gastroenterocolitis, 
pneumonia, typhoid with perforation, intussusception, perinephritic 
abscess, hernial strangulation, severe purpura hemorrhagica and the like. 
Even in such cases careful analysis of the typical symptoms of the re- 
spective diseases rarely fails to lead to a correct diagnosis. Chronic ap- 
pendicitis with recurrent acute exacerbations can usually be differentiated 
from renal calculi by x-ray examination and cystoscopy. 

Course and Termination. — The severity or mildness of the onset of 
an attack of appendicitis bears no positive relation to the further 
course of the disease. After the inflammatory process has, so to say, 
localized itself, which occurs usually within the first twenty-four or 
forty-eight hours, the physician is able in the majority of instances to 
conclude what sort of a case he is dealing with. By that time he will 
find that in catarrhal appendicitis the vomiting has partially or en- 
tirely ceased, the pain diminished, the abdominal rigidity lessened, 
and the tumefaction become less palpable. The child is able more easily 
to move about in bed, to have a few hours of comfortable sleep, oc- 
casionally to expel flatus, and to express a desire for food. Unevent- 
ful recovery may now take place within ten days, i. e., as far as sub- 
jective signs are concerned. In the majority of cases some morbid ana- 
tomic changes remain in the appendix and adjacent structures, e. g., in- 
flammatory adhesions, kinking, constriction of the lumen, etc. The re- 
gion of the appendix thus remains a locus minoris resistentice, for life, 
subject to recurrent attacks of inflammation and its sequelae. 

Sometimes after an apparently benign course of a few days' duration, 
either without discernible cause or as a result of gross errors in diet, 
undue exercise, and the like, there is a sudden change for the worse. 
The symptoms, spoken of as occurring with the onset, return, some- 
times even in more pronounced form; the patient vomits, has chills, 
headache, severe pulling and throbbing pain in the abdomen. The 
temperature rises, the pulse increases in frequency and tension, res- 
piration is quick but superficial (the patient is afraid to cough or take 
a deep breath owing to the increase of the pain with the descent of the 
diaphragm) ; the child is restless and sleepless, lies principally on his 
back with his right leg flexed (attempt to extend it aggravates the 
pain), and cries with pain on being moved about. Palpation reveals 
a distinct oblong tumor, the distended appendix, which is very ten- 
der, and gives rise to a gurgling sound on pressure. This physical sign 
is often absent in the so-called retrocecal appendical abscesses ! If the 
disease is not checked by operation, the indurated mass enlarges, loses 
its circumscribed character, becomes more doughy in consistency, and 



DISEASES OF THE ALIMENTARY TRACT 273 

dull on percussion; in short, it presents unmistakable signs of a fluid 
content — an abscess. This clinical picture of suppurative appendicitis 
does not by any means follow only the catarrhal variety; on the con- 
trary, quite often it is in full development within the first two or three 
days of the disease, and if the abscess is not promptly opened, it bursts, 
often giving rise to general peritonitis and quick death. More rarely 
the accumulation of pus occurs very slowly and gradually, and even 
remains in abeyance for a period of weeks or months, during which 
time the abscess becomes walled off from the general peritoneal cavity 
by inflammatory adhesions, and may finally be absorbed, or, with re- 
current attacks of appendicitis, perforate the sac and wander into any 
of the neighboring structures, sooner or later leading to the grave 
symptoms previously spoken of. 

In another group of cases — fulminating, gangrenous appendicitis — 
the symptoms are extremely alarming immediately from the begin- 
ning of the attack. In the midst of apparent good health, or preceded 
by slight malaise, vomiting, colic, prostration and collapse, following 
one another in rapid succession, and often without palpable local 
appendicular tumefaction, or other signs pathognomonic of appendi- 
citis, the typical picture of general septic peritonitis is in its full sway, 
— sometimes within twenty-four hours (usually after from three to 
five days) carrying the little victim to the grave. In such cases post- 
mortem examination reveals either preexisting infection of the peri- 
toneum, or sloughing of a gangrenous appendix, involvement of ad- 
joining blood vessels (thrombophlebitis) and general sepsis (pyemia). 

Treatment. — In view of the uncertainty of the course of the disease, 
every case of appendicitis should sooner or later be operated upon. 
This opinion is in accord with that held by the best modern clinicians. 
The profession is still divided, however, on the question of the time 
when operative procedures prove most propitious for the patient's 
uneventful recovery. In solving so difficult a problem, the physician 
must be guided (1) by the condition of the patient, and (2) the prog- 
ress of the disease. 

1. The Condition of the Patient. — It certainly would be folly to 
operate on a child in a moribund condition, or on one synchronously 
suffering from a systemic fatal disease per se, e. g., miliary tuberculo- 
sis, diabetes, grave heart or kidney disease, and the like. An operation 
should, if feasible, be deferred in infants under six months of age, be- 
cause of the lack of resistance of the patient, and in view of the fact 
that in very young infants spontaneous recovery (at least temporary), 
by absorption of the pus, or rupture of the abscess in the rectum, is 
by no means rare. 



274 DISEASES OF CHILDREN 

2. Progress of the Attack. — Mild catarrhal appendicitis, with the 
first attack, progressing favorably during the first four days, may be 
left alone until the quiescent stage, when the appendix should be 
removed. Severe or recurrent catarrhal appendicitis, failing to im- 
prove after the fourth or fifth day or showing incipient symptoms of 
suppuration (increased leucocytosis), should be operated upon at 
once; or, if for some reason an operation cannot be undertaken, it 
should be treated medically for a week or ten days longer, until the 
abscess has become circumscribed and encapsulated, when an opera- 
tion should be performed without further delay. The same rule ap- 
plies also to all cases of slowly developing suppurative appendicitis, 
the physician being constantly on the guard, however, for sudden 
threatening symptoms of perforation, — in the latter event demanding 
prompt surgical interference. Finally, an immediate operation is im- 
perative in all cases of perforative and gangrenous appendicitis, pro- 
crastination proving almost invariably fatal. 

When a patient is seen early, it is advisable to administer one dose 
of castor oil or calomel with bicarbonate of soda, to wash out the 
stomach (in the presence of vomiting) and intestines — to clean the 
alimentary canal of its contents. This should be followed by an oc- 
casional administration, in the form of suppositories, of very small 
doses of codeine or opium, to arrest peristalsis and to keep the child 
perfectly at rest and free from severe pain. No medication by mouth. 
During the acute stage of the disease, the constant application of ice 
is useful to relieve pain and arrest rapid progress of the inflammation. 
Thirst should be relieved by small quantities of water or tea ; and so long 
as anorexia exists, no attempt at forced feeding should be tolerated. An 
occasional teaspoonful of milk or broth will prove sufficient to sustain 
life for days. Any indiscretion in the diet is hazardous. I have fre- 
quently observed recurrence of an attack after partaking of cold drinks 
or ice cream. More liberal feeding may be practiced after subsidence 
of the acute symptoms, after repeated escape of flatus or of partly 
formed stool. Even then extreme caution is commended, limiting the 
dietary to slowly increasing quantities of milk, broths; albumin water; 
in older children, fresh soft-boiled eggs, milk toast, small portions of 
fine cereals, etc. For marked tympanites, atropine and morphine hypo- 
dermically. Stimulation by means of strychnine and normal saline 
solution, both subcutaneously, should be resorted to in accordance with 
indications. As the patient recovers, medication in the form of stomach- 
ics, intestinal antiseptics and laxatives may be administered by mouth, 
and the supply of nutritious food increased, so as to heighten the pa- 
tient's vitality for an early operation. Children convalescing from an 



DISEASES OF THE ALIMENTARY TRACT 275 

attack of nonoperated appendicitis should not be taken to any resort 
where a competent surgeon is not within immediate reach. Danger al- 
ways lurks behind a diseased appendix. 

Peritonitis Acuta 

Acute, nontuberculous peritonitis is of rare occurrence in children. 
The primary form is usually due to infection of the peritoneum by the 
B. coli communis, streptococci, staphylococci, or pneumococci, or by a 
combination of them. It is occasionally also encountered as a result of 
direct violence or secondarily in connection with infectious diseases 
e. g., typhoid fever, scarlatina, diphtheria, pneumonia, dysentery, vulvo- 
vaginitis, appendicitis and extension of other pus foci. In the new- 
born it not rarely forms a partial manifestation of sepsis (q. v.). 

Acute peritonitis usually sets in with very acute symptoms : excessive 
pain and tenderness of the abdomen, rapidly developing tympanites, at 
first often diarrhea, later constipation, scanty urination, or complete 
anuria; sometimes distinctly localized exudation; which may be dis- 
cerned by dulness in the flanks; high fever, especially during the first 
few days, more particularly in the perforative forms, and a feeble, rapid, 
and very poor pulse; dry and brown tongue, anxious and pinched ex- 
pression of the face, and, as the disease progresses, collapse. As a rule, 
marked leucocytosis prevails. The course of the disease varies. Hyper- 
acute peritonitis ends fatally usually in two or three days; moderately 
severe cases may last a week, and then terminate either in death or in 
gradual recovery. To the latter class belong also the cases usually of 
pneumococcus origin in which the pus becomes encysted, and breaks 
through the umbilicus, rectum or bladder. 

In a case (girl four years old, ill five weeks) I recently saw in con- 
sultation, the onset was sudden with vomiting, pain, and high fever. 
These symptoms subsided after a week, leaving behind very marked ab- 
dominal distention, slight, irregular fever, constipation and distinct 
flatness over the entire lower abdomen. Palpation also revealed very 
pronounced enlargement of the spleen. I concluded that we were deal- 
ing most probably with a secondary purulent peritonitis and suggested 
laparotomy, which would prove beneficial also were the case to turn out 
to be tuberculous peritonitis. This was done the following day. Over a 
quart of freely-flowing, foul-smelling pus escaped through the abdominal 
opening and the patient made an uneventful recovery. Apparently the 
peritonitis was of appendical origin. 

At all events the prognosis is very grave. It is almost always fatal 
to the newborn, and in cases resulting from intestinal perforation. 
Traumatic peritonitis offers the most favorable outcome, and local peri- 



276 DISEASES OF CHILDREN 

tonitis with encapsulated abscess often yields to prompt and suitable 
treatment. Protracted cases may be complicated by pleurisy, pericar- 
ditis, meningitis and general pyemia. 

The treatment, of course, depends entirely upon the underlying con- 
dition. It is justifiable to recommend an operation (laparotomy) in all 
cases of acute general peritonitis that fail to respond to medical treat- 
ment within forty-eight hours, and in those resulting from perforation 
of an abdominal viscus, e. g., appendix, intestinal perforation in typhoid. 
(For "differential diagnosis," see p. 267.) 

The medical treatment consists of perfect rest for the body and im- 
mobilization of the intestine. This may be secured by the hypodermic 
administration of morphine (1/60 grain for a child two years old) and 
atropine (1/1000 grain), the application of an ice bag or light turpentine 
stupes to the abdomen, and discontinuance of any nourishment until vom- 
iting has completely ceased. Vomiting is best arrested by lavage, sodium 
bicarbonate, bismuth subcarbonate, or minute doses (m. 1/30) of tinc- 
ture of iodine. After arrest of vomiting, feeding may very cautiously be 
resumed. Breast-fed babies may again be put to the breast and bottle-fed 
babies should receive small quantities of milk, gruel, beef juice, Tokay 
wine, champaign, and, if improvement continues, a light mixed diet. For 
excessive tympanites, the long rectal tube may be tried, allowing it to 
remain in situ for hours at a time. Or the saline "Murphy drip" 
the latter having the effect also in draining the abdomen of its toxic 
products and acting as a stimulant. Cases running a protracted course 
sometimes do well on daily local inunction of ung. hydrargyri (y 2 dram), 
and the iodides internally. Localized abscesses should be incised and 
drained. In slow convalescence, a sojourn at the seashore will prove 
beneficial. (For "Tuberculous Peritonitis.") 

Intestinal Worms 

Worms gain entrance into the human system chiefly through the 
ova, either consumed with food and water, or carried to the mouth 
by means of the fingers. We distinguish the following varieties of 
worms : 

(a) Oxyuris Vermicularis (Seat-, Thread, or Pinworm). — Small, 
white, thread-like, freely movable worm, 14 to y 2 inch in length. Its 
chief seat is the rectum where it causes intense itching. It may also 
infest the colon, cecum, appendix and vagina (vulvovaginitis). 

(0) Ascaris Lumoricoides (Roundworm, Nematoda). — Cylindrical, 
reddish gray in color, from 4 to 10 inches in length. It resembles the 
earthworm in form. Its chief seat is the small intestine, but it may mi- 



DISEASES OF THE ALIMENTARY TRACT 



277 




Fig. 62. — Oxyuris vermieularis. Female and male. (After Leuckart.) 




Fig. 63. — Ascaris lumbricoides. (1, Tail of male; 2, and 3, moutli — anterior and pos- 
terior; 4, excretory pore.) 




Fig. 64. — Tenia saginata. a. Natural size of the worm at different sections, d. 
Head (Avith pigment canalieuli). c. Proglottides. (Partly after Leuckart and Len- 
liartz, F. A. Davis Co.) 



278 



DISEASES OF CHILDREN 



grate to the stomach, gall bladder (icterus), throat, etc., in the latter 
location occasionally producing attacks of suffocation. 

(c) Teniae (Tapeivorms, Cestoda). — They are segmented worms of 
variable size. They inhabit the intestine and develop by budding. 




Fig. 65. — Tenia solium, a. Head. b. Proglottides. (After Leuckart.) 




Fig. 66. — Bothriocephalus latus. a. Worm, in sections; natural size. &. Head; 
lateral and front views. (After Leuckart.) 



DISEASES OF THE ALIMENTARY TRACT 279 

(d) Tenia Mediocanellata s. Saginata (Beef Tapeworm). — It is sev- 
eral yards long. The head presents at its middle a pit-like excavation 
and four anterior suckers. 

(e) Tenia Solium (Pork Tapeworm). — It is shorter than the former. 
It is provided with four suckers, one proboscis, and a wreath of hooklets. 
After invading the human stomach, the liberated embryos may wander 
to various portions of the body (skin, heart, brain, and eyes) and there 
develop into small vesicles (cysticercus) and lead to serious disturbances. 

(/) Bothriocephalus Latus (Fish Tapeworm). — Several yards long, 
possesses about 3,000 segments, a flattened head with two shallow suc- 
tion grooves. May be the cause of severe anemia. 

(g) Tenia Nana. — About 1 inch long, possesses a head with four suck- 
ers and a wreath of hooklets. May cause stubborn diarrhea. 

(70 Tenia Cucumerina s. Elliptica. — From 5 to 15 inches long; 
develops from swallowing dog ticks which infest the hair of dogs and 
cats. 

(i) Tenia Echinococcus. — It inhabits the intestines of the dog. The 
latter transmits the ova to the human gastrointestinal tract through 
the mouth, by licking, etc. The embryos develop chiefly in the liver and 
lungs, forming cysts. 

Symptomatology. — In times bygone the laity looked upon intestinal 
worms as the source of all ills, and even the physician was frequently 
inclined to hold the same view. As a matter of fact, worms, with but 
few exceptions, rarely produce very serious disturbances. Indeed, 
numerous round- and tapeworms may infest the human intestines 
often without any indication of their presence until accidentally dis- 
covered in the stools. Among the signs which are otherwise said to 
indicate their presence are the following: A pale complexion, black 
rings under the eyes, fetor ex ore, capricious appetite, picking at the 
nose, recurrent urticaria, colic, headache, vertigo, apathy, mydriasis, 
pavor nocturnus, grinding of the teeth, and dry cough. Some authors 
claim to have observed divers neuroses, convulsions, chorea, trismus, 
epilepsy, amblyopia, strabismus, and the like. The majority of the re- 
ported cases of this sort, however, do not bear close scrutiny and are 
readily traceable to other causes. The actual harm done by some of the 
worms has been mentioned under each heading. 

Diagnosis. — The diagnosis can readily be made by macro- and micro- 
scopic examinations of the stools and sputum (echinococcus hooklets) 
for Avorms or their ova. The finding of intestinal parasites may be 
facilitated by the administration of anthelmintics. 



280 DISEASES OF CHILDREN 

Treatment. — Santonin and calomel act very efficiently in thread- 
and roundworms. 

I£ Santonini, 

Hydrargyri chloridi mitis....aa gr. vj | 0.4 
M. et div. in pulv. no. vj. 

S. — One powder to be given every morning, on an empty 
stomach for a child three years old. 

To expel teniae the following is a very useful combination : 

I£ Ext. aspidii fi 3iij 12 

Emulsi chlorof ormi 3iv 15 

M. Emulsi amygdalarum .... q. s. ad Sij 60 
S. — Two teaspoonfuls as a dose for a child three years old, to 
be administered as follows: 

The day before the diet should be restricted to fluids. In the eve- 
ning the patient is given a few pieces of salt herring, followed an 
hour later by a purgative (castor oil or calomel). The next morning 
the male fern should be administered on an empty stomach, followed 
within half an hour by a dose of castor oil or calomel. If only part of 
the tapeworm escapes, and the other part remains inside, the torn 
end should by means of adhesive plaster be fixed to the buttocks, 
and another dose of the anthelmintic and oil administered until the 
rest of the worm has been expelled. 

The effect of anthelmintics by mouth is greatly enhanced by enemas 
of soapsuds and turpentine (y 2 dram to 1 pint) or a decoction of quassia 
wood (1 ounce to 1 pint). Quassia injections are very useful- in pin- 
worms, especially if followed by local application of gray ointment 
In older children the fluid extract of male fern may preferably be given 
in capsule form. The rare attacks of asphyxia from round-worms, 
previously spoken of, are best relieved by turpentine administered 
by mouth (on lumps of sugar) or by rectum, and prompt expulsion of the 
worm by santonin. 

Ankylostomiasis, Uncinariasis 

(Hookworm Disease) 

Although prevailing in this country for many years past, this af- 
fection has only recently, principally through the efforts of Dr. Charles 
W. Stiles, received due recognition as the "American murderer." It 
is practically endemic throughout the South, but is met with sporadi- 
cally also in other states of the Union. 

The disease is caused by the hookworm which infests the human 
body either through the mouth (by swallowing of infected water or 
food), or through the skin, especially the skin of the feet (the larva? 



DISEASES OF THE ALIMENTARY TRACT 



281 



of the worm gradually entering the circulation), and ultimately set- 
tles in the upper portions of the small intestines. 

The hookworm comprises two species : Ankylo stoma duodenale (old- 
world species), which is endemic, especially in Italy and Egypt, and 




Fig. 67. — Ankylostomum duodenale. a. Male. ~b. Female, c. Head. d. Natural 

size. (After Leuckart.) 




Fig. 68. — Uncinaria Americana. (1, mouth capsule; 2, mouth cavity.) 

Uncinaria americana or Necator americanus (the new- world species). 
Both species measure from about % to % inch in length (the females 
somewhat larger than the males), but while Ankylostoma carries on its 



282 DISEASES OF CHILDREN 

head four hook-like teeth on the ventral side and two smaller vertical 
teeth on the dorsal side, the Uncinaria has a dorsal pair of prominent 
semilunar plates or lips, and a ventral pain of smaller plates of similar 
nature. 

By means of its armed mouth the worm fixes itself to the intestinal 
mucosa, producing minute erosions and hemorrhagic spots, and sooner 
or later a more or less severe catarrhal process in the alimentary tract. 
It is still a matter of diversity of opinion whether the uncinaria feeds 
on the epithelial cells of the mucosa or upon blood. However this may 
be, the blood certainly undergoes marked changes, in severe cases, re- 
sembling the blood findings of primary pernicious anemia. Leukocytosis 
with eosinophilia is the rule. Very soon other organs of the body are 
affected, especially the liver and spleen. 

Postmortem examination usually reveals fatty degeneration of the 
liver; softening of the spleen and paucity in lymphoid elements; neph- 
ritic changes in the kidneys ; pallor of the lungs ; flabbiness of the heart, 
and anemia of the brain and effusion into the ventricles. 

Hookworm disease is most destructive in the young. Usually dermati- 
tis of the feet and legs forms the first symptom. Children remain 
stunted in physical and mental development, they look tired, old, 
apathetic, and owing to the pumness of the face not rarely resemble 
cretins. The skin is sallow, the fingernails and the sclerse are white or 
bluish-white. They suffer from palpitation of the heart, dyspnea, head- 
ache, dizziness, tinnitus, nausea, occasionally vomiting and abdominal 
pain. The appetite is either poor or voracious, often accompanied by 
a desire for unnatural food (pica), eating of earth, dirt, rags, etc. With 
increasing anemia there is frequently dropsy in the subcutaneous tissues 
and serous cavities — the edema often masking the emaciation and flabbi- 
ness of the body musculature. 

Occasionally the disease runs quite a rapid course, the patient dying 
from exhaustion within a few weeks. 

The diagnosis of hookworm disease is based upon a macroscopic and 
microscopic examination of the stools for the worm and its ova. 

Treatment. — Thymol acts specifically in this affection. It may be 
administered in an emulsion with acacia or, in older children, in the 
form of capsules, the thymol crystals being first triturated with sugar 
of milk. The following mode of administration is recommended: 
Late in the afternoon the patient receives 2 grains of calomel (no cas- 
tor oil) and the next morning 1 dram of Epsom salts. After the bowels 
have thoroughly acted, 5 or 10 grains of the thymol is given on an 
empty stomach, and, if indicated, the dose is repeated after an hour. 



DISEASES OF THE ALIMENTARY TRACT 283 

The patient is kept in bed, without food, until late in the afternoon. 
Some clinicians recommend oil of chenopodium instead of thymol. 
The feces should again be examined for uncinaria after the lapse 
of from two to four weeks. 

DISEASES OF THE LIVER 

Icterus Catarrhalis 

(Catarrhal Jaundice) 

Catarrhal icterus (catarrh of the ductus choledochus) occurs as fre- 
quently in children over four years of age as in adults. It is compara- 
tively rare in infants, except in the newborn. (See p. 231.) As a rule, 
it is caused by and associated with gastroduodenal catarrh, and begins 
with coated tongue, anorexia, nausea, vomiting, and slight rise of tem- 
perature. (In another group of cases which is of microbic origin (epi- 
demic icterus or Weil's disease), the onset is sudden, with high fever, 
apathy, delirium, headache, and vomiting, so that before the appearance 
of the icterus cerebral disease is first thought of.) In a day or two it is 
usually found that the urine is brownish yellow (bile stained), the fe- 
ces are gray and clayey, and the conjunctivas, scleras and skin yellow 
in color. This pathognomonic group of symptoms increases in intensity 
up to about a week, and then begins to diminish, first with clearing of 
the urine. The pulse is usually retarded, about seventy beats to the 
minute when the child is at rest. Palpation and percussion reveal 
tenderness over the stomach and liver, and occasionally some enlarge- 
ment of the latter. This is particularly the case in catarrhal jaundice 
running a protracted course. 

The prognosis is favorable and under suitable treatment the symp- 
toms ordinarily subside within from ten to fourteen days. The treat- 
ment consists of restriction of diet to thin soups, albumin water, skim- 
med milk, tea and toast, boiled fish or chicken, and similar, easily di- 
gestible food, free from fat (no cream, eggs or pastries!). Grad- 
ual return to a heavier diet. Medicinally, a few small doses of calomel 
and bicarbonate of soda, and daily intestinal irrigation (with 2 quarts 
of water at 90° F.) will usually suffice to arrest the disease. Pancreatin, 
rhubarb and soda mixture, and sodium salicylate are useful remedies, 
and prolonged warm alkaline baths (1 pound of bicarbonate of soda to 
the bath) hasten recovery in chronic cases. 

Diseases of the Parenchyma of the Liver 

Primary disease of the parenchyma of the liver is extremely rare in 
children under twelve years of age, since its principal cause — alcohol- 
ism — is practically unknown in young children. On the other hand, 



284 DISEASES OF CHILDREN 

secondary involvement of the liver is not infrequently met with in 
connection with syphilis, tuberculosis, chronic suppurative processes, 
malaria, rachitis, valvular heart disease, protracted gastrointestinal 
disease, and infectious fevers. In these conditions the symptomatol- 
ogy is the same as in adults. 

Cirrhosis of the Liver 

1. Atrophic Cirrhosis. — After a prodromic stage of several weeks, 
consisting chiefly of gastrointestinal disturbances, emaciation, tym- 
panites, ascites, slight enlargement of the spleen, and dilatation of the 
abdominal veins gradually complete the clinical picture of the disease. 
The atrophy of the liver usually sets in insidiously, as a result of 
gradual hardening and contraction of the connective tissue. The course 
of the disease is shorter in children than in adults. Hemorrhages from 
the stomach and nose and into the skin not rarely occur toward the 
end of the disease, and progressive ascites hastens fatal termination. 

Case Report. — C. H., male, six years of age, was of healthy German parents. 
When barely a few months old he was frequently given a taste of beer, to initiate 
him, as it were, in the national custom. He liked it immensely from the start, 
and as he grew older this beverage served very handily as a prompt pacifier to sub- 
due his ungovernable temper. He was breast fed up to twenty months, and when 
he was weaned he stubbornly refused to drink cow's milk. Beer again proved 
the most alluring substitute. It was given to him either cold, mixed with the yolk 
of an egg, or in the form of " Bier-Suppe," i.e., boiled beer with small squares of 
toasted rye bread. The boy did exceedingly well for several years. At last he began 
to suffer from frequent attacks of indigestion. Every article of food was blamed 
for his upset stomach except the beer; and, as on the advice of the family physician, 
his diet was restricted to the limit barely to sustain his life, beer again stood 
him in good stead in times of distress. When I saw him he was greatly emaciated. 
His abdomen was immensely enlarged, very tense and traversed by large tortuous 
veins, and revealed the presence of a large quantity of fluid. It was utterly impos- 
sible to palpate the intraabdominal organs. I withdrew about three pints of clear, 
yellowish fluid, and was then enabled to determine the absence of any growth or tume- 
faction in any portion of the abdominal cavity, and the great reduction in the size 
of the liver. 

2. Hypertrophic Cirrhosis. — This disease is characterized by consid- 
erable enlargement of the liver, pronounced icterus, very marked en- 
largement of the spleen, and a protracted course. Ascites is absent 
until very late. The children usually remain stunted in growth. The 
liver is of very hard consistence. 

3. Congestive Cirrhosis (Cardiac Cirrhosis, Cardiotuberculous Cir- 
rhosis). — Pathologically it is characterized by hypertrophy of the 
liver and spleen, obliteration of the pericardium, and by tuberculous 
pleuritis and peritonitis. Intense ascites forms the principal clinical 
symptom. 



DISEASES OF THE ALTMENTARY TRACT 285 

4. Sugar-Cake or Sugar-coated Liver (Pericarditic Pseudocirrhosis 
of the Liver — Pick's Disease). — This form of liver disease is closely 
allied to the former variety. It is a progressive, incurable affection 
of unknown etiology. 

Treatment. — Since small quantities of spirituous liquors have proved 
to be the cause of quite a few cases of hypertrophic cirrhosis of the liver 
in children, it is essential to interdict its use in children, unless in- 
tended for temporary therapeutic purposes. 

The iodides and mercury should be given a fair trial in all forms of 
cirrhosis irrespective of cause. The ascites may be relieved by tap- 
ping, if diuretics, cathartics and heart stimulants fail to do so. Bland 
diet. Sojourn at the seashore. 

Acute Yellow Atrophy 

Its course is very violent, sometimes ending fatally within a few 
days. The s} T mptomatology is the same as in the adult : high fever, 
icterus, hematemesis, bloody stools, cerebral symptoms. 

Fatty Liver 

Anemia and emaciation are the principal symptoms. The liver is 
often moderately enlarged. The stools are grayish, pasty. The course 
is chronic. 

Amyloid Liver 

It is often associated with amyloid degeneration of the spleen and 
kidneys, and secondary to some wasting disease, especially chronic 
suppurative processes in the bones and joints. The hepatic and 
splenic dulness is enlarged, but pain on pressure, jaundice, or ascites 
are absent, unless the portal circulation is interfered with by enlarge- 
ment of the glands in the portal fissure. 

Attention to the cause, and to the dietetic and hygienic measures, 
may prove effective to arrest the degenerative process. 

Abscess of the Liver 

This condition is occasionally observed in children, most frequently 
as a result of extension of septic processes from neighboring structures, 
e. g., suppurative appendicitis, phlebitis umbilicalis, typhoid or dysen- 
teric intestinal ulceration. It may follow traumatism, invasion by round- 
worms, suppuration of echinococcus cysts, or of the mesenteric glands. 
The abscess may perforate into the thorax, intestines, or externally. 

Symptomatology. — Chills, hectic fever, tenderness over the liver; 
sometimes fluctuation and pus on aspiration. 



286 



DISEASES OF CHILDREN 



Treatment. — Free incision and evacuation of the pus as soon as the 
diagnosis has been established. 



Tumors of the Liver 

Benign, as well as malignant, tumors of the liver are occasionally 
observed in young children and even in the newborn. Cystic degen- 
eration is most common, and cases of carcinoma, adenocarcinoma 
and, more rarely, sarcoma are on record. These growths should 
not be confounded with gumma of the liver — a positive Wassermann 
reaction and the effect of specific treatment being most decisive in the 
diagnosis. 

Differential Diagnosis 



Chills 

Fever 

Tenderness 

Icterus 

Fluctuation 

Dulness 

Aspiration reveals 



Lung symptoms . Absent 



LIVER 
ABSCESS 



Marked 
Hectic 
Marked 
Slight, early 
Moderate 



Highest in mid- 
axillary line 
Pus 



HYDATID CYST 


PLEURISY WITH 


SOLID TUMOR 


OF THE LIVER. 


EFFUSION 


OF THE LIVER 


Absent 


Slight 


Absent 


Absent 


Moderate 


Absent 


Absent 


Absent 


Moderate 


Late 


Absent 


Marked, late 


Pronounced 


Absent, diffuse 


Absent 


" hydatid 


flat area, un- 




vibration ' ' 


influenced by 
inspiration 




Highest in mid- 


Lowest in mid- 


Irregular 


axillary line 


axillary line 




Nonalbuminous 


Albuminous 


Blood 


fluid with 


fluid which 




' ' hooklets ' ' 


coagulates orj 
boiling. Pus 






in pyothorax 


=: 


Absent 


Present 


Absent 



CHAPTER VI 

DISEASES OF THE RESPIRATORY SYSTEM 

General Remarks 

The inherent frailty of the infantile respiratory tract is very con- 
ducive toward its morbidity. The nasopharyngeal passages being 
very narrow and winding — intended to halt air impurities and to 
moisten and warm the inspired air before its entrance into the larynx 
—functionate to their own detriment in localities where the air is 
dust-, smoke- and dirt-laden, and where atmospheric changes are 
many and marked. Thus, the child being unable to clear its nose, 
the detained foreign bodies irritate the delicate, highly vascular 
mucous membrane, before long forming a nidus for bacterial inva- 
sion. As we shall see later, "a cold in the head" is quite common 
in infants, and, while per se harmless in its immediate effect, is often 
serious in its remote results. The local congestion by its repeated re- 
currence produces a locus minoris resistentiw not only of the mucous 
membrane of the nose, but, by extension and persistence, of the in- 
flammatory changes (hypertrophy), of the pharynx and adenoid tissue 
as well. With ensuing nasopharyngeal obstruction breathing now pro- 
ceeds principally through the mouth; the air no longer undergoes the 
preparatory process of filtration, moistening and warming, but reaches 
the larynx in its impure, irritating state, sooner or later giving rise to 
a catarrhal inflammation of the larynx and neighboring structures. 
This condition is soon aggravated by the continuous affluxion of foul 
nasopharyngeal secretion, and by the inability of the little patient to 
clear its throat by forceful expectoration. Furthermore, the thorax 
being short and narrow, its musculature thin and feeble, and the heart 
and thymus gland comparatively large, the more or less compressed lung 
is greatly hampered in free aeration and in ridding its distantly located 
portions of the obnoxious inflammatory products. Hence the pertinac- 
ity of apparently insignificant pulmonary lesions, the frequency of un- 
resolved pneumonia and pyothorax, and the insidious development of 
asthma, bronchiectasis and emphysema. As the child grows older, the 
nasopharyngeal tract larger, the thoracic cavity more spacious and, syn- 
chronously, the respiratory function more forceful, there is a correspond- 
ing reduction in the frequency and persistency of respiratory disease, not- 
withstanding, or, perhaps, because of the increased exposure of the child 
to atmospheric changes and infection. 

287 



288 DISEASES OF CHILDREN 

DISEASES OF THE NOSE AND THROAT AND EAR 

Rhinitis Acuta 

(Coryza) 

Acute coryza is a frequent affection of childhood. It may occur 
primarily as a result of bacterial infection or follow exposure to ther- 
mic, mechanic or chemic irritation, or set in in association with measles, 
influenza, scarlatina and diphtheria. The infectious variety often oc- 
curs in epidemic form. 

Primary coryza, if mild in character, gives rise to sneezing, slight 
rise of temperature, anorexia, etc. On the other hand, if severe in 
form, especially in infants, it usually begins with vomiting, fever, oc- 
clusion of the upper air passages by mucous or mucopurulent secretion, 
secondary conjunctivitis, and sometimes with convulsions. Owing to 
thickening of the nasal mucous membrane there is partial or total ob- 
struction to nasal breathing, giving rise to interference with suckling, 
dyspnea, and even acute attacks of asphyxia. The latter are prone to oc- 
cur especially in the newborn who are very apt to "swallow" the tongue. 

Every case of acute rhinitis associated with severe local (pseudo- 
membranous deposit) and systemic (vomiting, rapid loss of strength) 
symptoms should arouse the suspicion of being diphtheritic or scarla- 
tinal in character. 

Acute rhinitis is not rarely complicated by otitis, laryngitis and bron- 
chitis and exceptionally by sinusitis (in older children). The prognosis 
is generally good, although in young infants convalescence is slow. 

Treatment. — Avoidance of exposure to all atmospheric changes, 
even as regards temperature in the room. Cleansing of the nostrils by 
repeated instillation of a few drops of a 2 per cent solution of bicar- 
bonate of soda, alternated with lukewarm mentholated olive oil or 
albolene. Careful feeding, if necessary, by the spoon. As measures of 
temporary relief, we may recommend local applications of atropine (^ 
per cent), cocaine (1 per cent), or suprarenal solutions (% per cent), 
and camphor and the salicylates and quinine internally. There should 
be more or less strict isolation of the patient. Attention should be paid 
to constitutional symptoms. Serum therapy, whenever it is indicated 
(diphtheria). 

I£ Natrii salicyl gr. xii 0.8 

Pulv. camphoree gr. iii 0.2 

Chocolate q. s. 

M. Div. in pulv. no. iv. 
S. — One powder every two hours for a child three years old. 



DISEASES OF THE RESPIRATORY SYSTEM 289 

Rhinitis Chronica 

(Nasal Catarrh, Ozena) 

It is characterized by marked congestion and thickening of the nasal 
mucous membrane and hypersecretion — hypertrophic rhinitis, or by 
atrophy of the various layers of the mucous membrane and foul-smell- 
ing incrustation — atrophic rhinitis, ozena. The latter form is rarely 
observed in children under ten years of age. In the nursling it is often 
due to lymphatism or more rarely to hereditary syphilis (syphilitic 
rhinitis). 

Chronic rhinitis is usually the result of repeated attacks of acute 
coryza or other affections of the nasopharynx associated with nasal 
hypersecretion and obstruction to free nasal breathing (adenoids). In 
the presence of foreign bodies in the nose, the catarrh is usually uni- 
lateral. The disease is generally manifested by persistent coughing, 
enlarged lymph nodes at the angle of the jaw, oral breathing and other 
symptoms which usually accompany adenoids (q.v.). 

Treatment. — As all forms of chronic rhinitis by respiratory inter- 
ference and secondary glandular infection give rise to more or less 
impairment of the constitution, the treatment of this condition should 
embrace local, as well as general, therapeutic measures. The naso- 
pharynx should be kept clean by antiseptic and oily sprays and the 
congestion allayed by painting the mucous membrane twice or three 
times a week with 5 to 10 per cent of argyrol or solargentum, or tannin- 
glycerine, etc. Excessive hypertrophy should be reduced by trichlor- 
acetic acid and similar caustics, and, if these fail, by means of the 
galvanocautery or nasal scissors. In older children correction of de- 
viated septum. 



J$ Thymolis gr ii 

Olei eucalypti m v 

Albolene q. s. ad % ii 

M. 

-Nosespray, to be used morning and evening 



0.15 
0.3 
60.0 



Epistaxis 

(Hemorrhage from the Nose, Nosebleed) 

Bleeding from the nose may be due, primarily, to traumatism, ex- 
ternal irritation of the mucous membrane from various causes, foreign 
bodies, etc. ; or it may occur as a result of vascular excitement during 
the course of febrile (typhoid, pneumonia), circulatory (especially after 
exertion) and pulmonary diseases ; and hemorrhagic affections (hemo- 
philia, leukemia). In girls it may occur as vicarious menstruation. 



290 DISEASES OF CHILDREN 

Treatment. — The treatment of epistaxis varies, of course, with the 
cause. In slight hemorrhage, simple compression of the alae nasi 
against the septum acts efficiently. A bland ointment introduced in 
the nares before the child retires will usually prevent recurrence of 
the bleeding. 

In case of moderate bleeding, sitting posture, head erect, with hands 
folded over the head, and ice application to the nose and nape of the 
neck, or instillation of cold water (with some lemon juice, vinegar, 
alum or potassium permanganate) into the nose will usually suffice. 
If this fails, the nares should be packed as far back as possible with 
pledgets of cotton or gauze, dipped in a strong solution of alum, 
peroxide of hydrogen, or suprarenal gland solution. In secondary 
epistaxis due to vascular congestion, a small dose of morphine hypo- 
dermically in conjunction with the aforementioned measures will 
often act very promptly. As the last resort, we turn to the postnasal 
tampon, which, as a rule, checks the hemorrhage unless hemophilia 
is the underlying condition of the bleeding, when the treatment must 
be directed chiefly against this affection (q.v.). 

Detection of the local causes is very essential. Every visible bleed- 
ing spot should be cauterized with chromic or nitric acid or with the 
galvanocautery. Constitutional symptoms, if present, should receive 
prompt attention. 

Tumors and Foreign Bodies in the Nose 

Mouth breathing, snoring, and nasal speech are not due solely to 
adenoid vegetations or large tonsils. Not infrequently obstruction to 
breathing is the result of the presence of mucous polypi (soft, jelly- 
like), fibrosarcomas (hard and pedunculated), or foreign bodies. The 
latter are usually beans, pebbles, cherry stones, and so-called rhino- 
liths. Sooner or later they give rise to a (unilateral) foul, bloody dis- 
charge and implicate the lacrimal duct and Eustachian canal, and form 
a reflex cause of persistent irritable cough and asthmatic symptoms. 
The diagnosis can readily be made by inspection or x-ray examination. 

Treatment. — Tumors should be removed with the cold snare, gal- 
vanocautery, or by torsion with a slender forceps. Bleeding may be 
arrested in the manner outlined above. 

Foreign bodies if anteriorly situated can readily be removed by 
air inflation through the free side, or by means of a pointed forceps. 
If impacted farther back, it is preferable to dislodge the foreign body 
with a slender hook or forceps under cocaine, and either extract it 
anteriorly or force it posteriorly into the nasopharynx. 



DISEASES OF THE RESPIRATORY SYSTEM 



291 




Fig. 69. — Toy ring in antral cavity giving rise to empyema of the antrum of High- 
more in a child three years old. 



Sinusitis 

In children over five j^ears of age, exceptionally in younger ones, we 
occasionally meet with infections in the accessory sinuses in connec- 
tion with severe rhinitis, influenza, infected adenoids, etc. In the 
acute stage the children usually complain of pain at the seat of the 



292 DISEASES OF CHILDREN 

lesion, headache and occasionally dizziness. There is generally also 
a more or less profuse purulent discharge (unilateral if only one side 
is affected). In chronic cases the symptoms are usually masked and may 
be mistaken for those of rhinitis or adenoids. In doubtful cases the 
Roentgen ray will readily clear up the diagnosis. 

These cases are best managed by removal of underlying causes, spe- 
cial attention to cleanliness of the nasopharynx, instillations of argy- 
rol, etc. ; if these measures fail, the patient should be intrusted to 
the care of a rhinologist. 

Neglect of sinusitis may not rarely lead to serious consequences 
(meningitis !). 

Pharyngitis Acuta 

Acute pharyngitis is rarely primary (streptococcic infection), but 
quite frequently secondary in nature as a complication of acute rhi- 
nitis, tonsillitis, acute exanthematous affections, etc. Primary pharyn- 
gitis is ordinarily of short duration and manifested by dryness in the 
pharynx, pain in swallowing, and moderate rise of temperature. The 
pharynx is reddened, somewhat swollen, and often granular. 

Secondary pharyngitis will be considered in connection with the 
diseases it complicates. 

Treatment. — Attention to the bowels, rest in bed, Priessnitz com- 
presses to the neck and antiseptic sprays to the throat. Liquid non- 
irritating diet. 

Pharyngitis Chronica 

It may develop after repeated attacks of acute pharyngitis or as a 
result of extension of an inflammation from the adjacent structures. 
The posterior pharyngeal wall not rarely presents a deeply congested 
granular appearance, and is here and there covered by a tenacious 
mucous deposit. 

The affection is associated with more or less dryness in the throat, 
hawking and coughing. On examination, the fauces appear swollen 
and relaxed, the tonsils hypertrophied, and the esophageal opening 
covered by a thick, grayish-white deposit. 

Treatment. — Avoidance and removal of causes. Locally the parts 
must be kept clean by mild antiseptic sprays (DobelPs solution), and 
the swelling reduced by nasal instillations of a 5 to 10 per cent solu- 
tion of argyrol, silvol or solargentum, or by painting the throat with 
tannin-glycerine (5 per cent). Change of air, iodide of iron, cod liver 
oil, etc., are very helpful to effect a cure. 





Angina Follicularis 



Angina Herpetiformis, After Vesicles 
Burst 




Angina Ulcerosa (Vincentii) 

PLATE V 

(Courtesy of Dr. John Zahorsky.) 



DISEASES OF THE RESPIRATORY SYSTEM 293 

1* Suprarenal solution (1:2000), 

Dobell's solution aa % i | 30.0 

M. 

S. — Throat spray in acute or chronic pharyngitis. 

Angina 

(Sore Throat) 
Tonsillitis Acuta, Amygdalitis, Quinsy- 
Children under two years of age seem to present a decided im- 
munity against tonsillitis. On the other hand, all forms of angina 
are extremely common in children over two years old. Those with 
a "catarrhal habit" are especially prone to contract the disease. 
Streptococci, staphylococci and pneumococci among other micro- 
organisms, form the most frequent primary cause, and are productive 
of the usual symptom complex which is characteristic of similar con- 
tagious and infectious diseases of childhood. Thus, the attack is 
ushered in suddenly with a chill, rise of temperature (with evening 
exacerbations), vomiting (in younger children) and sometimes con- 
vulsions. The younger the child the less conspicuous the dysphagia. 
Hence the importance of a routine examination of the throat in all 
febrile affections. 

To avoid unnecessary repetition, it is advantageous to classify ton- 
sillitis in accordance with the tonsillar deposit as follows: — 

1. Angina Catarrhalis. — Redness and swelling of one or both faucial 
tonsils and adjacent tissues. Thin mucous exudation. 

2. Angina Follicularis. — The deposit begins as one or more white, 
small pellicles upon the middle or anterior portion of the tonsil. The 
white dots, at first distinctly isolated, soon coalesce to form yellow- 
ish- or greenish-white, elevated patches. These are removable without 
profuse bleeding, and reform slowly. 

3. Angina Epidemica (Septic Sore Throat). — The most common ap- 
pearance is that of follicular tonsillitis, but the constitutional symp- 
toms are much more severe and there is usually marked involvement 
of the cervical lymph nodes and a tendency to metastatic infection 
in remote parts of the body. Nausea, vomiting and other gastrointes- 
tinal symptoms often predominate. It occurs in epidemics and is 
usually traceable to infected milk. According to C. H. Dunn, septic 
angina may be complicated by peritonsillar abscess, suppuration of 
the cervical lymph nodes, arthritis, peritonitis, pleurisy, pericarditis, 
pneumonia, laryngitis, endocarditis, phlebitis, nephritis, and septice- 
mia. 



294 DISEASES OF CHILDREN 

4. Angina Parenchymatosa (Quinsy, Peritonsillar Abscess). — The 
tonsil (usually one) and peritonsillar tissue are intensely swollen, often 
displacing the uvula. It is bluish in color and doughy in consistency. 
The deposit, at first white, gradually turns yellowish-green, resembling 
the "point" of an abscess. Pus on puncture. 

5. Angina Herpetiformis. — The deposit begins with minute vesicles, 
which tend to burst and leave behind superficial ulcers. This form 
of amygdalitis usually involves both tonsils and is at times complicated 
by stomatitis. 

6. Angina Gangrenosa (Necrotica). — The tonsils are moderately en- 
larged and almost completely covered by a greenish-yellow, continu- 
ous, deposit surrounded by a red zone. The exudation if removed 
leaves behind a deeply seated ulcer. The deposit often spreads from 
one tonsil to the other by way of the anterior pillars, palatine arch 
and uvula. 

7. Angina Ulcerosa (Vincenti). — It greatly resembles the latter 
but is usually limited to one tonsil, and occasionally presents a pseu- 
domembrane. It is often associated with stomatitis. Vincent's bacillus 
in pure culture is almost always found in the exudation. 

The course of the different varieties of tonsillitis varies but slightly. 
After subsidence of the acute initial symptoms previously spoken of, 
the disease assumes a much milder aspect, except as to prostration, 
pain on swallowing, and evening exacerbations of the fever. The 
latter ranges between 102° and 105° F., and is especially high in fol- 
licular tonsillitis. More or less marked lymphadenitis is present in 
all forms of angina, and in accordance with the tonsillar involvement 
it is either unilateral or bilateral. Parenchymatous angina is not in- 
frequently associated with pseudotorticollis, and pain on moving the 
jaws is present also in the other forms of the affection. 

In uncomplicated cases, recovery is the rule in from three to ten 
days, but quite a number of deviations from the usual course are ob- 
served. Ulcerative angina usually lasts from two to three weeks. 
Tonsillitis is not rarely the forerunner of true diphtheria or rheu- 
matic affections with their respective complications, and cases are 
on record where it has proved to be the source of general septic or 
pyemic infection. 

Differential Diagnosis. — Angina may be confounded with influenza, 
glandular fever, diphtheria and scarlatina. In influenza the exudation 
is slight and not strictly limited to the tonsils ; marked adenitis is com- 
paratively rare. Furthermore, influenza is characterized by the simul- 
taneous presence of respiratory, digestive, and often nervous phenomena, 
while in tonsillitis throat symptoms predominate. Glandular fever dif- 



DISEASES OF THE RESPIRATORY SYSTEM 295 

fers from tonsillitis by the comparative absence of tonsillar manifestations 
and preponderance of glandular swelling (also of the bronchial, esopha- 
geal and retroperitoneal glands) . The distinction between severe cases of 
tonsillitis and moderately severe forms of diphtheria without a becterio- 
logic examination is often very difficult in the first twenty-four hours of 
the disease. In pharyngeal diphtheria the pseudomembrane appears as a 
small uneven, grayish white, slightly elevated patch upon the inner 
tonsillar or faucial surfaces of the throat. The deposit augments by 
rapid spreading, within a few hours reaching the posterior wall of the 
pharynx and adjacent structures. The surrounding uncovered areas 
are grayish in color, due to overcrowding of leucocyte nuclei and mucus 
beneath. The tonsils are only moderately large in size, but the sub- 
maxillary glands are large and hard, assuming the shape of a large 
walnut, and bulge conspicuously forward. The deposit, if removed, 
leaves a raw, bleeding surface and rapidly reaccumulates. Diphtheria 
bacilli are found in the throat. Tonsillitis with and even without 
erythema may be mistaken for scarlatina, and a differential diagnosis 
is sometimes impossible until a few days after the beginning of the 
attack. 

Treatment. — In view of the possible serious complications, tonsilli- 
tis should be arrested at its inception. The following mixture should 
be used every two hours as a local application, either undiluted, by means 
of a cotton swab in young children, or diluted 1 to 20 of water, as a 
gargle, in older ones : 



I£ Kesorcini 3 



ss 



2.0 



Acidi carbolici gr xx 1.3 

Pulveris camphorae gv x 0.6 

Aleoliolis i. 3ii 8.0 

Glycerini q.s. ad § ii 60.0 

M. 
S. — One teaspoonful in twenty of water as a 
gargle every two hours, etc. 

For the relief of pain, cold Priessnitz's compresses or an ice-collar 
to the neck, and salicylates internally. The latter is intended also to 
guard against rheumatic affections. In angina parenchymatosa, if sup- 
puration is inevitable, it should be hastened by hot applications and the 
abscess opened early. Copious irrigation of the throat with warm boric 
acid solution is often very efficient. Best in bed, liquid diet, plenty of 
water. Avoidance of transmission of the disease. (See "Diphtheria.") 
Pasteurization of milk whenever tonsillitis appears in epidemic form. 



296 DISEASES OF CHILDREN 



Hypertrophy of the Tonsils 



Chronic enlargement of the tonsils often develops after repeated at- 
tacks of angina or pharyngitis, not rarely follows scarlatina or diph- 
theria, and is frequently associated with adenoids. When the tonsils 
become so large as to obstruct respiration, the same symptom com- 
plex makes its gradual appearance as is pathognomonic of adenoids 
with which it is ordinarily associated. As in the latter anomaly, re- 
moval of the hypertrophied tissue is the only actual cure, and unless 
contraindicated by hemorrhagic diathesis, should be undertaken as 
early as possible, since the more or less degenerated tumors act not 
only as a cause of a number of reflex phenomena (e.g., enuresis), but 
as a harboring place for divers pathogenic bacteria, including the tuber- 
cle bacillus. As is well known, rheumatism is frequently traceable to 
infected tonsils. 

Treatment, — Until a few years ago tonsillotomy was looked upon as 
the operation of choice. Nowadays, however, tonsillectomy, or total 
enucleation of the tonsils, is generally preferred, especially if the 
tonsils are submerged. 

Tonsillotomy. — This is usually performed in the following manner : — 

The patient is placed on a table (if an anesthetic is to be used), or 
seated on a lap of an assistant or nurse. The arms are immovably fixed 
by means of a wide towel or sheet. The tonsillotome is introduced 
into the mouth like a tongue depressor and turned sideways and 
pressed against the base of the hypertrophied tonsil so that fts sum- 
mit protrudes through the circular opening of the tonsillotome. With 
the tonsillotome thus fixed and the thumb of the operator in the 
handle of the blade, the latter is firmly driven through the gland. 

The same procedures are repeated for the other tonsil. 

Tonsillectomy or Enucleation of Tonsils. — The patient is fully anes- 
thetized, the mouth widely separated with a mouthgag, and the field 
of operation highly illuminated. The right tonsil is grasped with 
long but fine tooth forceps, and beginning with the anterior superior 
portion of the tonsil and pillar, the tonsil is gently loosened from its 
attachments, by means of a right angled dissecting knife. The enu- 
cleated tonsil is then put on a stretch and severed from the adherent 
constrictor by means of a cold wire snare. The field of operation is 
kept free from blood and mucus by the suction apparatus. The same 
procedures are followed for removal of the left tonsil. Some surgeons 
recommend the application of a tonsil hemostat to prevent sudden 
hemorrhage. The patient is not allowed to leave the table until the 
throat is perfectly dry. Tonsillectomy is a more or less capital opera- 



DISEASES OF THE RESPIRATORY SYSTEM 



297 



tion, and calls for all the precautions, as regards preparation and after 
treatment, as do other serious operations. 

Postoperative Hemorrhage. — Slight bleeding requires no special 
treatment except ice-collar to the neck. Profuse hemorrhage should be 
promptly checked by tonsil hemostats, adrenalin and thromboplastin 
locally, and bj T all other therapeutic measures generally employed in 
severe hemorrhage. (See "Dangers and Accidents Attending Adenoid 
Operation," p. 300.) 

Adenoid Vegetations 

(Hypertrophy of the Nasopharyngeal or Luschka's Tonsil) 

The mucous membrane of the rhinopharynx is normally rich in lym- 
phoid or adenoid tissue which bears the name of nasopharyngeal or 
Luschka's tonsil. Like the faucial tonsils, the latter is subject to fre- 



£3£ 


^ 


w W 


1 


• 




4 

• 

j 


1 



Fig. 70. — Adenoids in a boy eleven years old. Note characteristic, dull, facial fea- 
tures and contracted chest. 

quent attacks of inflammation with secondary hypertrophy. Whenever 
the hypertrophied adenoid tissue assumes such proportions as to more 
or less fill the nasopharyngeal space and obstruct nasal breathing, a 
pathognomonic clinical syndrome develops which, though apparently 
insignificant in its lesion, is often very verious in its immediate and 
remote consequences. 



298 



DISEASES OF CHILDREN 



The clinical picture unfolds gradually, almost insidiously, growing 
more pronounced from time to time as the patient "catches cold." The 
child is unable to clear the nasopharynx, and the retained irritating 
nasal discharge helps to swell the adenoid tissue and to obstruct the 
rhinopharynx. He is thus forced to breathe through the mouth. As 
immediate results, we find that he constantly keeps his mouth open, es- 
pecially during sleep, which is greatly disturbed, and, as a rule, he 
snores heavily. As the nasal obstruction increases, he is frequently 
awakened by extreme dryness of the throat, and a croupy harassing 




Fig. 71. — Spinal curvature (stooping) secondary to adenoids. 



cough. In the morning he is tired, complains of headache, is drowsy and 
apathetic. His speech is dull, nasal (m and n sound like b and d), hesi- 
tating, and sometimes stuttering.* 

If it were possible to bring these little sufferers under proper treat- 
ment at this stage of the disease, quick and uneventful recovery would 
be the rule. Unfortunately, however, the laity, nay, the physicians as 
well, rarely think these symptoms of sufficient gravity to necessitate 



*It should be remembered, however, that the presence of adenoids does not necessarily pro- 
duce the typical symptoms of the disease. It all depends upon the proportionate size of the tumor 
to that of rhinopharynx. 



DISEASES OF THE RESPIRATORY SYSTEM 299 

medical and particularly surgical intervention. The deplorable con- 
dition is therefore allowed to proceed and the tumor to spread and 
sprout. The sequelae appear in rapid succession. The labored breath- 
ing sooner or later produces deformity of the thorax (pigeon breast) 
and often curvature of the spine. Owing to nonparticipation of the 
nose in respiration there is gradual atrophy of the levators alaa nasi 
et labii superior es, the depressors alse nasi, and the septum mobile. The 
nose becomes pinched and pointed, the external angle of the eye deeper 
than the internal, the lower lid droops, the lower jaw sinks down, and 
the face assumes that dull, fixed and irresolute expression which is so 
characteristic of adenoids. In addition to this, hearing is impaired as 
a result of secondary catarrhal inflammation of the Eustachian tube, etc. 
The child is absent-minded and dull of perception, does poorly at school, 
and becomes the target for abuse and corporal punishment by teachers 
and parents— all for no fault of his. When brought to the physician — 
often chiefly on account of impaired hearing — the diagnosis can readily 
be made by mere inspection. Such a superficial examination, however, 
should not be relied on, as similar symptoms are produced by nasal ob- 
struction from other causes (deformities, growths, foreign bodies, etc.). 
Inspection of the mouth reveals the bony palate high and narrow, leav- 
ing insufficient space for the teeth and causing their displacement. 
The faucial tonsils are greatly enlarged (in about 25 per cent of the 
cases), the posterior pharyngeal wall is granular, and, with the velum 
palati raised, often shows the distal ends of the adenoid vegetation. 
Rhinoscopy confirms the presence in the nasopharyngeal space of a pale- 
red, smooth, soft tumor which sometimes resembles a mass of earth- 
worms. It bleeds readily. The diagnosis is further corroborated by 
palpating with the finger the soft masses blocking the rhinopharynx, 
or by nipping off a small portion of the adenoid vegetations by means 
cf adenoid forceps introduced behind the velum palati. 

Treatment. — The diagnosis once established, the treatment should 
be prompt and energetic. Mild cases in their early stages may be ar- 
rested at their inception by scrupulous cleanliness of the nasopharynx, 
local applications of Lngol's solution or 2 per cent nitrate of silver, or 
5 to 10 per cent argyrol, silvol or solargentum, change of air, outdoor 
exercise, cold shower baths, and hematinics and alteratives internally. 
These procedures should also be followed in cases with hemorrhagic diath- 
esis where an operation is contraindicated for fear of uncontrollable 
bleeding, and in those associated with other grave affections, e. g., acute 
or subacute endocarditis. In all other cases, removal of the adenoids is 
the only actual cure, and should be undertaken as early as possible. 
The mode of procedure varies with each individual case. In voung 



300 DISEASES OF CHILDREN 

children under three years of age, the operation may be performed with- 
out (preferably with !) an anesthetic, in the sitting posture ; in older ones 
or in those who are hypersensitive to pain and shock, under primary 
anesthesia with ether (drop by drop method), ethyl chloride or bromide 
or nitrous oxide gas, in the recumbent posture. The child's arms are 
fastened to the sides of the thorax by a wide towel, and his jaws are 
separated by a mouth gag placed between the left upper and lower teeth. 
The operator stands on the right side of the patient and introduces the 
adenoid curette sideways into the latter 's mouth and passes it beneath 
the soft palate and up along the anterior wall until he reaches the vault 
of the rhinopharynx. The physician then implants the cutting edge of 
the instrument into the adenoid mass and makes a firm semicircular 
movement, directed backward, downward and forward. One such move- 
ment usually suffices to remove the tumor. It may be followed, however, 
by a few light, similar strokes, to smoothen the rough edges. The pa- 
tient is then turned on the side to allow the blood to drain into a basin. 
This may be facilitated by the injection of ice-cold water through the 
nostrils. After arresting the more or less profuse hemorrhage, which 
always accompanies the operation, the child is put to bed for a few 
hours until he has regained full consciousness and is kept indoors for a 
day or two on a nonirritating, cool, liquid diet. 

After-Treatment. — To prevent the recurrence of the adenoids, which 
is prone to take place in children with a tendency toward glandular 
hyperplasia, it is advantageous to instill into each nostril a few drops 
of Lugol's solution, once every other day for a period of about four 
weeks, and to use an oily antiseptic spray for several weeks thereafter. 
This procedure will prevent also adhesions between the cut surfaces 
and the soft palate. Delicate children should be put on syrup of the 
iodide of iron, cod liver oil, etc. To regulate nasal breathing, it is of- 
ten necessary by means of a bandage to keep the mouth closed, espe- 
cially at night, and to have the child take prolonged breathing exer- 
cises with closed mouth. Impaired speech sometimes calls for instruc- 
tion in speaking or, in the event of a paretic condition of the velum 
palati arising from inactivity, for treatment by electricity and tonics. 
In the majority of instances, however, the operation is followed by 
immediate restitutio ad integrum. All reflex symptoms and, to a great 
extent, even the deformities of the thorax subside rapidly. 

Dangers and Accidents Attending Adenoid and Tonsil Operations 

Simple and harmless as the operation is under ordinary conditions, 
it is not always free from danger. As in more serious operations, the 
possibility of fatality from the effect of the anesthetic or infection is 



DISEASES OF THE RESPIRATORY SYSTEM 301 

gravely to be borne in mind, and the frequency of primary or secondary 
— occasionally fatal — hemorrhage should engage the constant atten- 
tion of the operator. Hence the importance also of testing the coag- 
ulability of the patient's blood before the operation. 

To obviate untoward complications all such preparations should be 
made as are customary with capital operative work. Ethyl chloride 
and ether (drop by drop method) should be the anesthetic of choice, 
and primary in preference to deep anesthesia. The instruments to 
be used should be carefully sterilized, and the field of operation and 
everything coming in contact with it rendered as aseptic as possible. 
Before beginning the operation, the surgeon should test the efficiency 
and entirety of his instruments, and see to it that he is amply sup- 
plied with all such drugs (peroxide of hydrogen, suprarenal gland 
in solution 1:1000, thromboplastin, the tincture of chloride of iron, 
etc.), and with implements (postnasal tampon, artery forceps, sponge 
holder and styptic gauze — which can be used to exert direct pressure 
upon the bleeding spot; actual cautery, etc.), as will enable him 
promptly to check profuse hemorrhage. Postoperative fever is generally 
due to some form of throat infection and hence should promptly be 
treated by local application of tincture of iodine or argyrol (25 per cent 
solution). 

Retropharyngeal Abscess 

(Retropharyngeal Lymphadenitis) 

Retropharyngeal abscess is a disease of early infancy and childhood 
when the retropharyngeal lymph nodes are in a state of highest develop- 
ment. It usually begins as retropharyngeal lymphadenitis, most fre- 
quently the result of infection by offensive nasopharyngeal discharges. 
More rarely it is due to spondylitis of the cervical vertebra?, or occurs 
as a metastatic abscess, or in consequence of trauma. Not all cases of 
lymphadenitis undergo suppuration ; on the contrary, quite a number 
retrogress and escape attention. Hence the apparent rarity of retro- 
pharyngeal disease. Some cases undergo suppuration and break spon- 
taneously, and others run a rather latent course, and when seen by 
the physician present fully developed abscesses. Digital examination 
of the throat usually reveals, at a late stage, a round or oval fluctuating 
mass the size of a pigeon's egg, in the median line of the pharynx, and 
more rarely, laterally on a line with the velum palati or somewhat be- 
low it. In the more advanced stages the abscess may be recognized as 
a bluish-red tumor on ordinary inspection of the pharynx. 

The symptoms vary with the size of the tumor. In marked cases they 
consist of dysphagia, snoring respiration, especially during sleep, muffled 



302 



DISEASES OF CHILDREN 



voice and with progressive growth of the swelling, dyspnea and attacks 
of asphyxia. Where deglutition is very painful there is also sympa- 
thetic pseudotorticollis. Occasionally the submaxillary, parotid and 
other neighboring glands are involved; and in spontaneous rupture of 
the abscess metastatic abscesses are apt to develop in the ear and the 
supraclavicular fossa, mediastinum, and lungs. The temperature is usu- 
ally high in the early stage of the disease, and remittent later. 

Treatment. — Early opening of the abscess is therefore imperative. 
This is best accomplished by gently perforating it by means of a 
pointed artery clamp and widening the puncture by opening the clamp. 



a 







Fig. 72. — Ketropharyngeal abscess in a ten-month- old infant. Note characteristic at- 
titude of mouth, head and neck. 



Before opening the abscess the child's head is held upright and stead- 
ied from behind by an assistant. As soon as the perforation is made, 
the child's head should be promptly bent forward to prevent the pus 
from entering the larynx (danger of asphyxia, aspiration pneumonia, 
etc.) and the nose and throat cleared of blood, pus and mucus. 

In multiple communicating abscesses with palpable involvement 
of the adjacent gland, the operation is preferably performed (with a 
knife) from the outside, so as to afford thorough drainage. Sometimes 
it is of advantage to poultice the abscess for a few days before open- 
ing it. 



DISEASES OF THE RESPIRATORY SYSTEM 303 

Relief from the symptoms is very prompt after evacuation of the 
pus. Rapid recovery, however, occurs only in primary streptococcic 
or staphylococcic abscesses. In metastatic and tuberculous abscesses 
(especially the latter) the disease proceeds a protracted course, the 
prognosis depending upon the original disease and the age and vitality 
of the patient. General attention to the nasopharynx. Hematinics. 

Otitis Media 

(Otitis Externa, Furunculosis, Foreign Bodies in the Ear, 

Mastoiditis) 

The gravest feature of nasopharyngeal affections, be they primary or 
secondary, is their great tendency to ear complications. The naso- 
pharynx and ear being in direct communication through the Eustachian 
tube, infectious material can readily travel from the nose and throat 
to the middle ear and transfer the disease from one locality to the other. 
Hence the frequency of ear disease in rhinitis, adenoids, divers exan- 
thematous affections, influenza, etc. Only a small percentage of cases of 
otitis media are contracted through traumatism, sea bathing, or ex- 
tension of an inflammation from the external auditory meatus; and, in 
infants, middle-ear disease with masked symptoms is occasionally ob- 
served in connection with wasting diseases (e. g., tuberculosis, marasmus, 
syphilis). Epidemics of ear disease are not rare. 

The infection may remain limited to the Eustachian tube (catarrh of 
the Eustachian canal), and give rise to very few and mild symptoms. 
The child may complain of earache for a day or two, perhaps, wake 
up at night with a crying spell, but get immediate and usually perma- 
nent relief after application of heat or some "ear drops." Sometimes 
the pain may return and get much more intense, and examination of 
the drum would show injection of the drum or, perhaps, a slight muco- 
purulent discharge indicating spontaneous rupture of the membrane. 
The discharge may continue for a few days or weeks and disappear 
without further ado. In another group of cases, due to greater virulence 
of the infective material or, possibly, neglect, the inflammatory process 
pursues a more violent course (otitis media p undent a) . The tempera- 
ture rises, the earache is very intense, (but may be absent ! ) , the child is 
very restless, cries almost incessantly, rubs or strikes the ear with its 
hands, and, as the symptoms persist, there may be vomiting and cere- 
bral irritation up to convulsions. If the pus is not evacuated, we soon 
find that it eats its way into the deeper structures, leading either to an 
acute or chronic involvement of the bone (mastoiditis) . In severe in- 
fections this stage of the disease is often reached within a few days. The 



304 DISEASES OF CHILDREN 

aforementioned constitutional symptoms are greatly exaggerated. The 
local signs — in addition to intense earache, deafness, headache and 
marked congestion of the drum — are also augmented by tenderness over 
the mastoid process and by edema of the tissues covering the bone, ex- 
tending downward along the entire side of the neck and backward to the 
retromaxillary fossa, pushing the auricle forward. The upper and 
lower walls of the meatus are more or less swollen and the drum is highly 
inflamed, bulging and irregular in contour, while the posterior supe- 
rior quadrant of the drum with the adjacent wall of the canal is sag- 
ging. The further course of the affection depends greatly upon the mode 
of treatment. If the inflammatory process is allowed to continue, the pus 
may find its way either externally, somewhere along the side of the neck, 
into the throat (retropharyngeal abscess), or, in malignant cases, into 
the lateral sinus (phlebitis, thrombosis) or the middle fossa of the skull 
(meningitis, purulent encephalitis) . The same grave condition is some- 
times observed in otitis pursuing a very slow course — months or years. 
In these cases it is usually found that the patient is suffering from re- 
current attacks of earache with or without profuse purulent discharge, 
more or less severe headache, dizziness, occasional rise of temperature, 
tenderness over the mastoid process, and, toward the end, loss of weight, 
anorexia, persistent headache and repeated vomiting. 

The disease having reached this deplorable stage, one is very rarely 
apt to err in the diagnosis. A question may arise as to whether the 
meningeal symptoms are secondary to otitis or to some other affection 
(e.g. j pneumonia, sepsis), or primary in character. A history of ear 
disease and the presence of local ear symptoms (discharge, inflammation 
of the drum, etc.) at once point to its true nature. Nor is there any 
difficulty in diagnosing otitis media purulenta with acute symptoms. 
The diagnosis, however, is not so easy in cases with an insidious course. 
It is especially difficult when the ear symptoms are masked by mani- 
festations of the primary affection (e.g., influenza), but an electro- 
otoscopic examination almost invariably clears up the diagnosis, and 
should always be resorted to whenever inexplicable pain or tempera- 
ture prevails. In fact, no examination of a baby is complete without 
such an examination. Only very recently I had occasion to find double 
otitis in a boy fourteen months old who, for three weeks, was treated 
by a prominent clinician for "central pneumonia." Mild cases of middle 
ear disease may be mistaken for otitis externa. In this affection, how- 
ever, the local signs are limited to the external auditory canal (redness 
and narrowing of the meatus without involvement of the drum). Simi- 
larly, middle ear disease may be confounded with furunculosis or foreign 
bodies in the auditory meatus, but these can readily be eliminated by 



DISEASES OF THE RESPIRATORY SYSTEM 303 

an otoscopic examination showing* the seat of the lesion. Occasionally 
an abscess in the external canal burrowing itself through the cartilagi- 
nous portion of the canal in back of the ear may be mistaken for mastoid 
abscess; in such cases constitutional symptoms and inflammation of the 
drum are absent and the abscess is superficial and communicating with 
the swelling in the external canal. 

Treatment. — Bearing in mind the great tendency of nasopharyn- 
geal affections to lead to ear disease, and the latter to become a source 
of everlasting misery and death, it is self-evident that all precautions 
should be taken to prevent the causes and their dreadful results. Dur- 
ing the course of acute febrile, especially exanthematous diseases, 
the nasopharynx should receive especial attention in the way of care- 
ful, gentle cleansing. Warm salt water or albolene, or some silver 
preparation should be instilled into the nose twice daily, preferably 
with a spoon or dropper, lest forcible syringing may drive the dis- 
charge from the nasopharynx into the Eustachian tube. Hypertrophied 
tonsils and adenoids should be removed (during the quiescent stage 
of the otitis!) and chronic nasopharyngeal catarrh treated with ap- 
propriate remedies. The instillations should also be continued after 
the appearance of ear symptoms, and as long as the membrane is in- 
tact syringing of the ear with warm boracic acid solution will prove 
beneficial. If the otitis continues and the drum does not rupture 
spontaneously, free paracentesis, preferably under primary anesthesia, 
should be performed without delay, to allow the pus to escape. The 
mode of after-treatment is still subject to controvery, several prom- 
inent otologists preferring the "dry" method (drying of the external 
auditory canal several times a day and loosely draining with absorbent 
gauze) to repeated syringing. Some otologists recommend to cleanse 
the ear once a day by suction and to follow it up with packing. Where 
the discharge continues, instillation of a few drops of a 2 per cent 
solution of nitrate of silver, or in very chronic cases cauterization 
of the tympanum with trichloracetic acid will be found to act splen- 
didly. If sensitiveness over the mastoid is detected and the consti- 
tutional symptoms show that the disease is rapidly growing worse, an 
attempt should be made to arrest its progress by a new paracentesis, 
ice bags and leeches and, if improvement does not set in early, there 
is nothing else left but immediately to proceed with opening of the 
mastoid process with a chisel to prevent the pus invading the sinus, 
meninges or brain substance. In the majority of instances a radical 
mastoid operation is a life-saving procedure. Unfortunately, this 
operation is not rarely undertaken either too late or on a patient in 
a state of very low vitality from the baneful effect of the primary 



30G DISEASES OF CHILDREN 

disease, so that the results are not always very gratifying. It is 
questionable whether operative interference is to be advised after the 
disease has spread to the meninges or brain. The recoveries in these 
cases are certainly very few and far between. 

Pain should be relieved by small doses of codeine, and other symp- 
toms arising should be met in accordance with indications. Change 
of air often works wonders in recalcitrant cases. 



0.333 
0.133 
15.00 



0.003 
15.00 



J£ Acidi Phenolis gr v 

Mentholis gr ii 

Glycerini 3 iv 
M. 

S. — "Ear drops," in acute cases. 

Iy Hydrargyri Chloridi Corrossivi gr ss 

Alcoliolis 3 iv 
M. 

S. — ' ' Ear drops, ' ' in chronic cases. 

Deafness 

From a study of 1,076 congenitally deaf children, Yearsley reports 
heredity and consanguinity to be the most important factors; with al- 
coholism, insanity, and syphilis the most important minor causes. Of 
592 cases of acquired deaf-mutism 72.2 per cent were due to suppura- 
tive or catarrhal middle ear disease, in which infectious fevers and 
adenoids played an important part. Statistics collected by other 
clinicians show similar data regarding the etiologic factors^ of deaf- 
ness. 

Testing the Hearing. — The acuteness of hearing is determined by 
the watch test and the voice test applied separately to each ear. Dur- 
ing both the watch and the voice tests, the eyes of the patient should be 
closed, in order that lip reading may not be possible, and that the 
distance of the watch or the speaker may not influence the patient. In 
tests relative to differential diagnosis and prognosis the tuning fork 
is used. 

Weber's Test.— In this test a C 2 tuning fork, having 512 vibrations 
per second, is vibrated and the handle placed against the upper central 
incisor teeth or upon the middle line of the cranium. If the sound is 
heard better in the afflicted ear it is indicative of some affection of the 
conducting apparatus, such as middle ear disease, impacted cerumen 
in the external auditory canal, or occlusion of the Eustachian tube ; 
while if heard better in the normal or less afflicted ear, it is the per- 
ceptive, or nerve, apparatus that is at fault. 

Rhine's Test. — This test depends upon the fact that the normal ear 



DISEASES OF THE RESPIRATORY SYSTEM 30? 

is more sensitive to sounds transmitted through the air than to those 
transmitted by the bony framework of the ear. In a normal ear, 
if the handle of a vibrating' C 2 (512 vibrations) tuning fork is held 
against the mastoid until the patient no longer hears any sound, and 
then the free tips of the fork be brought close to the external ear, the 
sound will be heard again. This is known as positive Rinne. If, how- 
ever, the sound is not heard again when the fork is thus transposed, it 
is known as negative Rinne. In a defective ear, a negative Rhine test 
shows a relative reduction of aerial conduction or a similar increase in 
bone conduction and indicates obstruction or disease of the normal con- 
ducting apparatus ; while a positive Rinne test, in a defective ear, is an 
indication of a lesion in the perceptive apparatus of the internal ear. 

Schwabach's Test. — This test depends upon the fact that in middle 
ear disease, a fork vibrating in contact with the cranium is heard longer 
in an affected than in a normal ear. TVTien the auditory nerve is af- 
fected, it is heard longer by the normal ear. The fork is struck and 
placed on the patient's mastoid and when the patient ceases to perceive 
the sound, the fork is transferred to the examiner's mastoid. If still 
heard by the normal ear of the examiner, it indicates labyrinthine dis- 
ease in the patient. If not heard, the test is reversed, the examiner first 
placing the vibrating fork on his own mastoid, and, when the sound has 
died away, transfers it at once to the patient's. If heard by the patient 
after the examiner's normal ear has ceased to hear it, an obstruction 
of sound condition, but not disease of the nerve, is indicated. 



Interpretation of Above Tests 

A negative Rinne test indicates middle ear disease which should 
be partly or entirely benefited by treatment. A positive Rhine test 
indicates nerve deafness which, with a few exceptions, implies an 
unfavorable prognosis. The Schwabach test deduces an abnormal con- 
dition of the conducting apparatus (middle ear) when bone conduction 
is lengthened and, conversely, disturbance of the nervous mechanism 
when bone conduction is impaired. The "Weber test is only valuable 
in indicating disease of the perceptive apparatus in unilateral deafness, 
when the sound is accentuated in the normal ear; the chief objection 
to the test being the uncertainty of the localization of the auditory 
perception in one ear. Tuning-fork tests are said to be of value as aids 
to prognosis when they point to middle ear disease. However, the deduc- 
tions drawn from these tests should be used with caution as the pitch 



308 DISEASES OF CHILDREN 

and intensity of the sounds employed may sometimes cause them to 
vary and even to be the direct opposite of what the formulated rules 
would lead us to expect, Even with indications of a diseased percep- 
tive apparatus, supported by many tests, an unfavorable prognosis 
should be withheld until treatment has been administered and found 
unavailing. 

Indications of Labyrinth or Auditory Nerve Deafness 

1. When the tuning fork is heard better through the air. 

2. When the power of hearing is better in a quiet place. 

3. When noises are markedly annoying. 

4. When inflation of the middle ear makes the hearing worse. 

Among the various tests employed in the diagnosis of labyrinthine 
disease that of Barany is without danger and may prove of service. 
According to Barany, when the vestibule is healthy, the injection of 
water at a temperature of, say 80° F. into the external auditory canal 
will develop a circular nystagmus toward the opposite side. On the 
other hand, if the temperature of the water be above that of the 
body, the nystagmus will be toward the ear syringed, while if the 
labyrinth be destroyed no nystagmus will develop. 

Treatment. — Careful attention to existing external and middle ear 
diseases. Tonics and electric vibration may prove beneficial in laby- 
rinth deafness. Iodides and mercury are always worth trying even if 
the Wassermann test is negative. 

Laryngitis Acuta 

(Catarrhal Laryngitis, Spasmodic or False Croup, Laryngitis Stri- 
dula, Membranous, Nondiphtheritic Croup) 

Acute primary, idiopathic laryngitis is comparatively rare in children, 
except as the result of the traumatic action of strong gases, vapors, 
fluids or excessive heat. On the other hand, laryngitis quite frequently 
occurs in conjunction with divers acute exanthematous diseases, espe- 
cially measles and influenza, often follows attacks of rhinitis, pharyn- 
gitis, tonsillitis and esophagitis, and may develop in connection with 
intra- and extra-laryngeal growths. This so-called secondary laryngitis 
affects children principally of from two to ten years of age. 

The severity of the symptoms is often by far out of proportion to 
that of the underlying anatomic lesion. Thus, simple hyperemia of 



DISEASES OF THE RESPIRATORY SYSTEM 309 

only a small portion of the laryngeal mucous membrane not rarely gives 
rise to marked symptoms of suffocation. 

Several forms of laryngitis are noted in practice : — 

1. Catarrhal Laryngitis. — The child complains of sore throat and 
sensitiveness of the larynx to pressure. The cough is dry, short, and 
barking; the voice husky or only slightly muffled. Respiration is nor- 
mal; fever is absent or slight, Expectoration is at first slight and of 
a mucous nature, later more profuse and mucopurulent. The attack 
lasts about a week. 

Occasionally, especially in neglected cases or in those suffering 
from affections of the nasopharynx, the laryngitis may pursue a 
chronic course with a tendency to permanent alteration of the voice. 
In this event laryngoscopic examination usually reveals a moderate 
hyperemia of the laryngeal mucous membrane, and in some cases slight 
erosions. 

2. Spasmodic Laryngitis (Laryngitis Stridula, False Croup). — It 
develops, either very suddenly or after a few days' illness, with ca- 
tarrhal laryngitis or nasopharyngitis. Sudden attacks usually occur 
in children under eight years of age, more frequently in boys than 
in girls. After retiring apparently healthy and sleeping fairly well 
until about midnight (this may also happen during the day after pro- 
longed sleep, when the nasopharyngeal or laryngeal secretion desiccates 
and gives rise to irritation of the larynx, and possibly edema of the sub- 
chordal tissue) the child wakes up with a harsh, croupy cough, inter- 
rupted by deep inspiratory stridor. The child looks frightened and anx- 
iously gasps for air, its face is flushed and bathed in perspiration, its eyes 
stare and its lips are cyanosed, and the whole clinical picture is very 
alarming. The dyspnea usually passes off in a few minutes, but may 
last hours with slight remissions and gradual improvement. Ordi- 
narily the child is well again in the morning except for a simple mild 
laryngitis which may subside in two to ten days or give rise to re- 
newals of the attacks for a few successive nights. Sometimes the 
paroxysm may be so severe as to require intubation or tracheotomy 
for immediate relief. Spasmodic croup occasionally forms the begin- 
ning of pertussis, measles, influenza or membranous, nondiphtheritic 
croup. It should not be mistaken for spasmus glottidis (q. v.). 

3. Membranous, Nondiphtheritic Laryngitis. — In the beginning the 
symptoms are those of simple laryngitis. Very soon, however, the ca- 
tarrh is increased in intensity. The cough becomes harsher and more 
croupy, the voice hoarse (sometimes aphonia), inspiration prolonged 
and expiration noisy. It may begin also with bronchial catarrh and 



310 DISEASES OF CHILDREN 

become suddenly complicated by fibrinous tracheolaryngitis — ascend- 
ing croup — reach a very high degree of intensity, become more severe 
from hour to hour, and threaten suffocation, if not immediately relieved 
by intubation or tracheotomy. The aspect is still worse when the croup- 
ous inflammation descends into the bronchi — bronchial croup. In this 
condition the patient may cough up white reticulated shreds (which 
float in water) or complete cylinders with dichotomic ramifications or 
multiple dendritic branchings. The prognosis in such cases is very 
grave. The pulse fails, the dyspnea and cyanosis increase, the patients 
fall into a state of sopor and die from collapse. Not infrequently fatal 
brain symptoms occur as a result of passive venous congestion in the 
brain and transudation in the ventricles. The course and termination 
of the disease, however, is not always so bad, and quite a number of 
uncomplicated (sometimes complicated by bronchopneumonia) cases re- 
cover without much ado. 

This noncliphtheritic form of laryngitis is often mistaken for diph- 
theritic membranous laryngitis, but a diagnosis can in the majority of 
cases be made with the aid of the following differential points : 

MEMBRANOUS DIPHTHERITIC MEMBRANOUS NONDIPHTHERIT- 

LARYNGITIS IC LARYNGITIS 

Diphtheria bacilli present. Absent. Streptococci, Staphylococci or 

Pneumococci present. 

Distinctly contagious, giving also a his- Not contagious. 

tory of contagion. 

Early enlargement of the submaxillary Submaxillary glands, as a rule, not in- 

glands. volved or slightly so. 

Diphtheritic patches are found, as a rule, The fauces may be covered with a mucous 

on the fauces and posterior pharyngeal exudation, which can easily be wiped 

wall. off. 

Albuminuria usually present. Absent. 

Treatment. — Mild cases do nicely on very simple therapeutic meas- 
ures, such as rest in bed, attention to the nasopharynx (instillations of 
warm boracic acid solutions several times daily; occasionally also 
5 per cent argyrol or silvol), hot baths, hot drinks (tea, lemonade, 
milk and seltzer, Priessnitz's compresses or turpentine and campho- 
rated oil to the neck and a few doses of sodium salicylate internally 
to relieve the sore throat and to stimulate diaphoresis. 

Should there be any tendency for desiccation of the laryngeal se- 
cretion, softening of the same should be endeavored by means of ex- 
pectorants, steam inhalations and emetics. In the majority of instances 
this mode of treatment prevents the occurrence of attacks of spasmodic 
laryngitis. 



DISEASES OF THE RESPIRATORY SYSTEM 311 

Iy Vini ipecaehuanhae 3 ss 2.00 

Syr. scillae comp 5 i 4.00 

Syr. senegae 3 ii 8.00 

Codeinae sulpli gr ss 0.033 

Ext. glycyrrhizae fl 3 ii 8.00 

Aquae q.s. ad § ii 60.00 

M. 

S. — One teaspoonful every two to four hours for a 

child 3 years old. 

I£ Eucalyptol 3 i 4.00 

Tinct. benzoini comp % ii 60.00 

M. 

S. — One teaspoonful in a pint of hot water for inhalation. 

Sudden paroxysms of false croup are best remedied by ice collar, 
prompt emesis, a hot mustard bath (see p. 92), a large dose of sodium 
bromide, a hypodermatic injection of morphine 1/20 grain and atro- 
pine 1/400 grain, counterirritation by a strong sinapism and, if the 
cyanosis increases notwithstanding, intubation or tracheotomy. 

The management of membranous nondiphtheritic croup is frequently 
quite a difficult proposition. Hence, the importance of its prevention 
by early attention to catarrhal laryngitis. Steam inhalation and 
emesis are useful remedies, and inhalation of a few drops of chloro- 
form is often effective to relieve threatening dyspnea. Severe cases 
call for early intubation or tracheotomy. Recurrent laryngeal spasm 
sometimes yields to spraying of the larynx with 2 per cent solu- 
tion of cocaine. As diphtheria antitoxin carefully administered is a 
safe remedy, it is always advisable to resort to it, although bac- 
teriologic examination of the pseudomembrane fails to reveal the diph- 
theria bacillus. Mixed antistreptococcic, staphylococcic and pneu- 
mococcic sera are also deserving of trial. 

Prophylaxis. — Removal of local causes, such as adenoids and large 
tonsils; change of air; tonics, especially cod liver oil. 

Laryngitis Chronica 

Chronic laryngitis may follow repeated attacks of acute catarrhal or 
diphtheritic laryngitis or develop slowly by extension of inflammation 
from the neighboring structures. Overexertion of the voice and excessive 
smoking in boys are occasional causes. 

Laryngoscopic examination shows hyperemia and swelling of the 
mucous membrane of the larynx which vary in extent with the duration 
of the affection. The mucous membrane is sometimes covered with 
granulations, and in severe cases shows more or less superficial ul- 
ceration. There is a moderate secretion of mucus and pus which has 



312 DISEASES OF CHILDREN 

a tendenc}^ to desiccate, and gives the sensation of a foreign body in 
the throat. The cough is usually insignificant ; occasionally, however, 
troublesome, harsh and barking, especially at night. 

Diagnosis. — Although syphilis and tuberculosis of the throat are 
comparatively rare in children, their presence should always be sus- 
pected and looked for in obstinate laryngitis. The following differen- 
tial points are helpful in the diagnosis: 





Simple Laryn- 
gitis 


Syphilitic 


Tuberculous 




SECONDARY 


TERTIARY 




Lesion 


Hyperemia, slight 


Mottled hyper- 


Deep, angry ul 


Anemia, grayish 




thickening, ero- 


emia, super- 


cers, cicatri- 


color, solid 




sion of mucous 


ficial ulcera- 


ces, stenosis. 


thickening, 




membrane, rare- 


tion. 




worm-eaten 




ly slight ulcera- 






ulcers. 




tion. 








Expectoration 


Free from tubercle 
bacilli. 


Spirochetes. 


The same. 


Bacilli present. 


Deglutition . . 


Usually painless. 


Normal. 


Difficult. 


Very painful. 


Cough 


Dry or moist, pain- 
less. 


Slight hacking. 


Infrequent. 


Severe, as a rule. 


Respiration . . 


Normal. 


Unaltered. 


Embarrassed 
with stenosis. 


Early accelera- 
tion. 


Voice 


Variable. 


Hoarse, nasal. 


Raucous, husky. 


Partial or com- 
plete aphonia. 


Complications 


Nasopharynx; gen- 


Syphilitic 


The same. 


Involvement of 




eral health unaf- 


lesions else- 




lungs, emacia- 




fected. 


where. 




tion. 



Treatment. — Attention to existing causes, especially adenoids and 
enlarged tonsils, if present; local application, three times a week, of 
nitrate of silver (1 per cent to 2 per cent), glycerate of tannin (10 
per cent), or chloride of zinc (2 per cent to 4 per cent) ; steam inhala- 
tion (see p. 311) ; cleansing of the nose and throat, three times a day, 
with DobeLTs solution, and the like, will very promptly effect a cure, 
provided the laryngeal affection is not based on some grave constitu- 
tional affection, or benign (papilloma) or malignant growths. Eest 
to the voice is of material benefit. In very protracted cases change of 
air and constitutional treatment. Faradization of the larynx is often 
very serviceable to relieve aphonia. 

Ty Codeinag sulph gr ss 0.033 

Creosoti carbon 3i 4.00 

Syr. acaciae q.s ad §ii 60.00 

M. 

S. — One teaspoonful every three hours for a child six years old. 



DISEASES OF THE RESPIRATORY SYSTEM 313 

Edema Glottidis 

(Submucous Laryngitis, Phlegmonous Laryngitis) 

Edema of the upper portion of the larynx occurs in two forms : Active 
(inflammatory, phlegmonous), and passive (serous). Inflammatory ede- 
ma may be primary, usually traumatic (e.g., scalds or burns), or sec- 
ondary, as a result of extension of inflammation from neighboring struc- 
tures. Passive edema is usually observed in connection with grave kid- 
ney and heart disease — often long before dropsy is manifested in any 
other part of the body — and secondarily to pressure on the larynx by 
swellings or growths. 

Pathologically edema of the larynx consists of a yellowish-white or 
reddish tumefaction — a serous, seropurulent or sanguinolent transuda- 
tion into the submucosa — involving the upper portions of the larynx, 
the epiglottis, the ary epiglottic folds, the false (rarely the true) vocal 
cords, and the mucous membrane of the arytenoid cartilages. 

These local changes can readily be detected by inspection of the 
larynx, often without the mirror, by simply depressing the tongue and 
pulling it forward, and by digital examination. 

The result of such swelling of the larj-ngeal tissues is quite obvious — 
namely, interference with normal respiration. The dyspnea is at first 
paroxysmal, and, if the edema is not very marked, only moderately se- 
vere. The poor little patient hacks and coughs, in vain trying to clear 
the throat. If the edema advances, which is apt to occur in severe 
traumatic cases, the dyspnea may become extreme, and symptoms of as- 
phyxia may set in which, if not promptly relieved, may lead to a fatal 
issue. 

Edema glottidis should not be mistaken for spasmodic croup or 
asthma ! 

Treatment. — Partial edema may be reduced by ice bags to the neck, 
swallowing of ice, local application of suprarenal extract solution 
(1:1000) and morphine and pilocarpine hypodermically. In severe 
cases, scarification and, if need be, tracheotomy should be resorted to 
in addition to the mode of treatment just outlined. Recurrence of an 
attack of passive edema should be prevented by prompt attention to 
the etiologic factors. 

Laryngeal Tumors 

Neoplasms of the larynx are very rarely seen in children. This is 
especially true of malignant growths. Granulomata are occasionally 
observed after tracheotomy. Papillomata are not quite so rare, and are 
sometimes congenital, in which event the symptoms usually appear soon 



314 DISEASES OF CHILDREN 

after birth. Their usual seat is at the true vocal cords, and if of con- 
siderable size they give rise to obstinate cough, hoarseness, dyspnea and 
attacks of asphyxia. These symptoms develop, however, gradually, and 
sometimes disappear spontaneously owing to retrograde metamorphosis 
of the tumor. Recurrences after removal of the tumor are frequent. 
Laryngeal neoplasms may be confounded with adenoids, retropharyngeal 
abscess and croup, but the diagnosis can readily be made by laryngo- 
scopy examination. Operative treatment should be instituted only in 
cases presenting troublesome symptoms. Endolaryngeal removal of the 
growth is the procedure of choice. Tracheotomy is indispensable in 
threatening asphyxia. 

Foreign Bodies in the Larynx 

Various articles of food, little playthings, buttons, needles, ascarides, 
etc., may find their way into the larynx. Small foreign bodies are usu- 
ally expelled by the attacks of forcible coughing. Large nonimpacted 
articles may be removed by an extubator or similar forceps after co- 
cainizing the upper part of the larynx. Foreign bodies firmly impacted 
in the larynx should be removed under anesthesia through the trache- 
otomy incision. In threatening asphyxia, tracheotomy should be per- 
formed immediately irrespective of subsequent procedures. To re- 
duce hyperemia, ice externally and internally. Local antiphlogosis 
(Lugol's solution, 1 per cent nitrate of silver) after removal of the 
foreign body. 

Anodynes for the relief of pain and irritability. (For removal of 
ascarides see p. 280.) 

Diseases of the Bronchial Tubes, Lungs and Pleura 
Bronchitis Acuta 

(Tracheobronchitis, Fibrinous Bronchitis, Capillary Bronchitis) 

As the term indicates tracheobronchitis is a catarrhal inflammation 
of the trachea and large bronchi. It usually develops, by extension, sec- 
ondarily to nasopharyngeal and laryngeal catarrh, either in association 
with ordinary colds or in consequence of specific infections such as in- 
fluenza, pertussis, diphtheria and the like. Occasionally it is met as a 
result of traumatism by irritating vapors or dust. Except for the 
harsh cough, which is at first dry and later soft and yielding, a moderate 
amount of mucous and mucopurulent expectoration, slight embarrass- 
ment of respiration, slight temperature and anorexia, simple bronchitis 
is usually a benign affection terminating favorably within a week or ten 
days. Its seriousness consists only in its tendency towards the develop- 



DISEASES OF THE RESPIRATORY SYSTEM 315 

merit in bronchopneumonia — which is most apt to occur in young in- 
fants or older children whose health has been undermined by previous 
illness. The physical signs are usually limited to diffuse large soft rales 
which temporarily disappear after brisk coughing. 

Fibrinous Bronchitis. — This form differs from simple bronchitis by 
the presence of membranous masses of mucus and fibrin in the ex- 
pectoration, in the form of bronchial casts. The casts correspond 
to the size and depth of the bronchi involved. Until relieved by the 
ejection of the casts, the patients suffer from more or less marked 
dyspnea and fever. 

Capillary Bronchitis. — In this form of the disease the small bronchi, 
the bronchioles, are involved, and it is often questionable whether or 
not the inflammation actually remains limited to the fine bronchi or 
extends to the pulmonary alveoli. As a rule, capillary bronchitis 
begins as a simple bronchitis, but as it progresses, its symptomatology 
is essentially the same as in the early stages of bronchopneumonia: 
thus, painful cough, more or less dyspnea, moderate or high fever, 
often vomiting and twitching, pallor, and cyanosis. Fine sibilant 
rales are heard over different portions of the chest, and sometimes 
also fine crepitation. Unless the affection is arrested in its early course, 
its transition into bronchopneumonia is the rule. 

Treatment. — The patient should be kept in bed in a well-ventilated 
warm room; the diet reduced to liquids, and the bowels regulated. The 
nasopharynx should be cleansed a few times daily with Dobell's solu- 
tion (50 per cent) or weak solutions of the newer silver prepara- 
tions. Inhalations of antiseptic vapors (with the compound tincture 
of benzoin and eucalyptol) may be added as a routine procedure. 
Where the cough is painful, and distressing, the flaxseed mustard 
poultice recommended in bronchopneumonia (q. v.) will often give 
relief and occasionally arrest the disease in its inception. The following 
preparations will be found very serviceable : 



IJ Liq. Ammonii Anisati 






Vini Ipecacuanhas 
Potassii Citratis 




aa 3 ss 
3i 


2.0 

4.0 


Syrupi Picis 
Glycerini 




aa 
3 iv 


15.0 


Aquas Anisi 
M. 


q.s. 


ad f I ii 


60.0 


S. — One teaspoonful 


every 


two to four hours, for a child three 


years old. 









Where the cough is very disturbing, it is advisable to add from 
1/24 grain to 1/16 grain of codeine to each teaspoonful of the medicine. 



316 DISEASES OF CHILDREN 

Occasionally I find it necessary to alternate this mixture with the fol- 
lowing : 

1} Creosoti Carbonatis 3 ss 2.0 

Glycerini 3 iv 15.0 

Pulv. et Mucilago Acacias q. s. 

Aquae Anisi q. s. ad f 3 ii 60.0 

M. 
S, — One teaspoonful every three to six hours for a child three 
years old. 

Bronchitis Chronica 

Chronic bronchitis is not very common in children. It may occur 
as a sequel of acute bronchitis or pneumonia, diphtheria, pertussis 
and heart and kidney diseases. It may gradually give rise to dilata- 
tion of the bronchi (bronchiectasis), emphysema or asthma, in which 
event the symptomatology resembles that of the other affections. 
A Roentgenogram is often helpful in the diagnosis. This procedure 
is especially valuable in the detection of foreign bodies in the bronchi 
and tuberculous foci. 

Treatment. — Attention to the nasopharynx and larynx. Inhalation 
of medicated vapors. Small doses of ammonium iodide or the syrup 
of hydriodic acid. Change of air. General tonics. (See also Asthma, 
Bronchiectasis, and Emphysema.) 

Broncho or Lobular Pneumonia 

Next to gastrointestinal diseases, bronchopneumonia is the most com- 
mon affection of early childhood. In the majority of cases it is caused 
by a mixed bacterial infection — of the pneumococcus, streptococcus, 
staphylococcus aureus, B. influenzas and B. tuberculosis. It frequently 
occurs also secondarily to the exanthematous diseases, pertussis, erysipe- 
las and chronic heart, kidney, and intestinal maladies. Recurrent colds, 
rachitis and other wasting diseases serve as active predisposing causes. 

The onset of bronchopneumonia may be sudden or gradual in asso- 
ciation with tracheobronchitis or capillary bronchitis, as a result of ex- 
tension of the inflammation. The pathologic process is usually bilateral. 
Small areas of pulmonary congestion, consolidation and resolution are 
scattered throughout the entire lung. On section the affected lobules 
present quite a smooth surface of bluish-red color. The bronchioles and 
pulmonary alveoli are filled with a mucosanguinolent and mucopurulent 
exudation. The bronchial walls are thickened and infiltrated with small 
round cells, and the lymph nodes are enlarged and congested. Quite 
often the pleura is implicated in the inflammatory process. 



DISEASES OF THE RESPIRATORY SYSTEM 317 

As already stated, transition of the inflammation from the large 
bronchi to the fine bronchioles (bronchiolitis) and lung tissue (pneu- 
monitis) not rarely proceeds insidiously, in fact, the bronchopneumonia 
may exist for a few days before being detected. This holds true espe- 
cially of bronchopneumonia accompanying influenza, measles and diph- 
theria. In the majority of cases, however, the onset is ushered in with 
rise of temperature (up to 105° F.), fretfulness, vomiting, and occa- 
sionally convulsions. The cough is dry, short and painful, the pulse 
and respiration are greatly increased in frequency. A pulse of 130 to 
160 beats per minute and a respiratory rate of from 40 to 60 are quite 
common. There is moderate dyspnea ; the alae nasi are contracting and 
dilating forcibly; the eyes are dull, and the face is pale and slightly 
cyanotic. In virulent cases the dyspnea gradually increases, the heart's 
action becomes weaker, and the patient rapidly succumbs to cardiac ex- 
haustion and toxemia, usually preceded by attacks of tachycardia and 
tachypnea, coma and convulsions. Even in favorable cases, the course 
of the disease is usually protracted, lasting from two to four weeks or 
longer, principally because of repeated extension of the pneumonic proc- 
ess to new areas, not rarely with resolution of the old foci. Furthermore, 
the course of the disease is often aggravated by numerous complications : 
as, for example, pleuritis, otitis, stomatitis and gastroenteritis, and quite 
frequently also by pyothorax. Where resolution is long delayed, bron- 
chopneumonia may also terminate in tuberculosis and pulmonary gan- 
grene. 

The physical signs are indefinite in the early stage of the affection. 
The face is flushed on one or both sides and with each inspiration there 
is more or less marked retraction of the soft structures in the intercostal 
and suprasternal spaces. The respiratory sounds are rough and accen- 
tuated, and here and there intensified by diffuse small and large sono- 
rous rales. As the disease advances and the localized pneumonic foci 
multiply, become consolidated and coalesce, we are soon able to detect 
the typical signs of pneumonia, i. e., dulness on percussion, bronchial 
breathing, bronchophony and occasional fine crepitation. An undue de- 
gree of flatness on percussion should be looked upon as a suspicious sign 
of pleuritis with effusion. 

The prognosis of bronchopneumonia is always very grave, especially 
in infants under one year of age, in whom the mortality ranges between 
20 and 30 per cent. Grave, often fatal, are usually the cases presenting 
the following symptoms : continued hyperpyrexia, pallor and cyanosis, 
marked tympanites, dyspnea with respirations irregular in depth and 
rhythm, coma and convulsions, and recurrent recrudescence of the pneu- 



318 DISEASES OF CHILDREN 

monic process after apparent defervescence. (Sec also Influenza- Pneu- 
monia.) 

Treatment. — Bronchopneumonia being most frequently the sequel of 
some other serious affection, it is therefore obvious that prophylaxis 
forms the sine qua non in our therapeusis. By viewing every simple na- 
sopharyngeal and bronchial catarrh as a precursor of lobular pneumonia, 
and by applying the proper means to arrest it at its inception, a great 
many cases could readily be prevented. Bronchopneumonia, once es- 
tablished, we have no specific to combat it. However, an attempt can 
yet to be made to modify the virulence of the disease by means of the 
following procedures. The patient is given a hot mustard bath of about 
three minutes' duration, is wrapped in a warm blanket, surrounded by a 
few hot water bags and given hot drinks, moderate doses of sweet 
spirits of niter or spirit Mindererus, etc., to stimulate free diaphoresis. 
This is soon followed by the application to the chest and back of a hot 
poultice consisting of six tablespoonfuls of flaxseed meal, three table- 
spoonfuls of camphorated oil, one or two tablespoonfuls of powdered 
mustard and a sufficient quantity of hot water to make a thick paste 
by thorough stirring. The mass is spread thickly on thin gauze. The 
child is then wrapped in an oiled silk jacket lined with absorbent 
cotton and blanket, which with the hyperpyrexia of the body, main- 
tain the heat of the poultice, so that its renewal is required but three 
or four times in twenty-four hours. The poultice is very useful, espe- 
cially where the breathing is painful and difficult. In these cases some 
benefit may be derived from the application of from twelve to twenty- 
four dry cups. Where the temperature is very high and the poultice is 
apt to interfere with the hydrotherapeutic procedures, we may resort to 
mustard cloths (wrung out of a mustard solution, one teaspoonful of 
mustard to a pint of warm water). The temperature should preferably 
be reduced by cool sponging, cool pack, ice cap to the head, and where 
cerebral symptoms prevail, by warm baths, with or without mustard, 
although an occasional dose of pyramidon, aspirin or phenacetin will do 
no harm. 

The maintenance of the child's strength is most essential to the suc- 
cessful management of the disease. Be it remembered that death in 
pneumonia is due to heart failure and not to pulmonary insufficiency; 
therefore, the heart must receive early and diligent attention. We may 
begin with the tinctures of digitalis and strophanthus (one drop of each 
for every year of the child's age up to about six years) every four to 
six hours, and more frequently if the circulatory and respiratory diffi- 
culty increases. In bad cases the stimuluation may be intensified by the 
addition of sterile camphorated oil (3 grains) and strychnine sulphate 



DISEASES OF THE RESPIRATORY SYSTEM 319 

(1/60 grain) hypodermically every four hours; and where signs of 
pulmonary edema supervene, by an occasional dose of atropine sul- 
phate (1/200 grain). In sudden collapse, suprarenal solution (5 to 10 
minims hypodermically) is worth trying. 

Every effort should be made to replenish the body fluids consumed 
during the active febrile process by suitable liquid nourishment, such 
as broths, beef tea, small quantities of milk or fermented milk, fruit 
juice, etc., in addition to large quantities of water. In extreme cases, 
saline entero- or hypodermoclysis, and, in older children, saline intra- 
venous may have to be resorted to. The urine should be watched for 
acetone and pus, the latter especially in girls. Excessive tympanites 
often yields to intestinal irrigations with bicarbonate of soda solutions 
(!/2 ounce to 2 quarts of water) with or without the addition of essence 
of peppermint (10 to 15 minims) or to pituitary solution hypodermically. 
This may be repeated two or three times in twenty-four hours. Com- 
plications arising should receive prompt attention. 

When called upon to treat bronchopneumonia with delayed resolution, 
our efforts should be directed mainly towards the prevention of empy- 
ema or tuberculous infiltration of the lungs. A great deal can be ac- 
complished by placing the patient in a large airy room during the 
febrile stage, and, weather permitting, keeping him outdoors most of 
the time, after the temperature has dropped to normal or to a degree 
above. During convalescence removal to the country is highly to be 
recommended. 

The iodides will often be found very useful to hasten resolution. We 
usually begin the administration of the sodium or ammonium iodide, 
in y 2 to 2 grain doses, about the sixth day of the disease, and continue it 
until resolution has been established. After the temperature has disap- 
peared, we give the syrup of the iodide of iron with the compound 
syrup of hypophosphites, which acts both as an alterative and tonic. 

Creosote is indicated in all stages of bronchopneumonia (see Prescrip- 
tion, p. 316). The ordinary beechwood creosote may also be used for in- 
halation by means of a croup kettle ( 10 to 20 minims in a pint of hot wa- 
ter). Its effect is intensified if a tent is improvised around the child's 
bed. 

If notwithstanding the aforementioned therapeutic measures the 
bronchopneumonia fails to resolve, and the physical signs and explora- 
tory puncture fail to disclose pus in the thorax, we must direct our at- 
tention to the possible presence of a latent or florid tuberculous process. 
The diagnosis between simple bronchopneumonia due to mixed infection 
and acute or subacute tuberculous bronchopneumonia is often very diffi- 
cult. In the tuberculous variety the onset is usually more gradual, the 
temperature curve more intermittent, the loss in weight more rapid and 



320 DISEASES OF CHILDREN 

the areas of consolidation more stationary in character, and giving rise 
to more definite physical signs, snch as flatness, bronchial breathing, 
bronchophony, etc. An exact roentgenogram is often decisive in the 
diagnosis, revealing, as it frequently does, marked involvement of the 
bronchial glands. The von Pirqnet test is usually negative in the non- 
tuberculous form. 

Lobar Pneumonia 

(Croupous Pneumonia, Fibrinous Pneumonia, Pneumonitis, Pneu- 

mococcus Pneumonia) 

Acute lobar pneumonia is a primary, specific, communicable, 
occasionally epidemic, affection of the lungs, pathologically character- 
ized by pulmonary engorgement, red hepatization, gray hepatization and 
resolution. The pneumococcus or diplococcus lanceolatus of Frankel- 
Weichselbaum, the immediate cause of lobar pneumonia, can readily be 
isolated — usually in pure culture — in the sputum, lung substance, and the 
blood, in four different groups — Type I, II, III, IV.* 

Pathology. — In the stage of engorgement or congestion the lungs show 
very little that is characteristic. They are dark red, still contain air, but 
are slightly firmer in consistence, and resemble mostly a beginning 
hypostatic pneumonia. Without the aid of the microscope it can be 
anatomically diagnosed best when fibrinous hepatization is to be seen 
immediately adjoining it. 

In the stage of red hepatization the alveoli become filled with red 
blood corpuscles and fibrin. On coagulation of the fibrin the hemor- 
rhagic contents of the alveolus become a quite firm, red plug. The cut 
surface of red hepatization is red and slightly granular. The latter 
gradually changes to grayish-red and, in part, grayish-yellow (gray 
hepatization). This is due to solution of the blood corpuscles, diffusion 
of the blood coloring matter, and exudation of new fibrin masses and 
partly also of cellular elements into the alveoli. The hepatized area 
thus attains a volume as in deep inspiration, with the difference, how- 
ever, that instead of air a firm exudate occupies the alveoli which pro- 
duces anemia of the lung tissues as a result of pressure upon the vessels. 
If the edge of a knife is held at a slant and scraped across the cut sur- 
face, grayish-yellow granules are obtained, which are composed of a 
dense network of fibrin inclosing a moderate number of colorless blood 
corpuscles and a few desquamated alveolar epithelia. This is the stage 
of complete hepatization. 



*Blanke and Cecil (Jour. Exp. Med., April, 1920) have shown that lobar pneumonia is 
bronchogenic in character. Invasion of the blood stream by pneumococci is secondary. 



DISEASES OF THE RESPIRATORY SYSTEM 321 

The cut surface gradually becomes smoother and redder, and the 
solid consistency gives place to a more relaxed condition. If the cut 
surface now be scraped with the edge of a knife, a cloudy fluid, partly 
mixed with solid masses, is seen, which consists microscopically of finely 
granular detritus, disintegrated cells and a few large, still coherent 
clumps or plugs. These plugs contain chiefly round cells and only a 
slight amount of fibrin. This is the stage of resolution, i. e., loosening, 
softening, transformation from the solid to the fluid state ; the exudation 
is partly expectorated and partly absorbed, as a result of a fermentative, 
proteolytic process (R. Langerhans and H. T. Brooks). 

Lobar pneumonia is generally accompanied by fibrinous pleuritis, and 
more or less marked bronchitis. As a rule, only one pulmonary lobe is 
affected, and the lower right more frequently than the others. If several 
lobes are involved, it usually occurs by successive invasion. 

Primary fibrinous pneumonia usually ushers in suddenly, often after 
exposure to cold or wet, with vomiting, chilliness, high temperature 
and more or less marked dyspnea. The initial symptoms are frequently 
misleading. They may consist of vomiting, diarrhea, pain in the abdo- 
men and nosebleed, suggesting the beginning of typhoid fever; or con- 
vulsions, sopor, vomiting and severe muscular pain may predominate, 
justifying the tentative diagnosis of meningitis. "Where the pneumonic 
lesion is located centrally (so-called central pneumonia), and the 
physical signs, nay, even the cough, is absent or very slight in the 
early stages of the disease, one is not rarely tempted to diagnose re- 
mittent malarial fever. Furthermore, there are also numerous cases 
of pneumonia of only a few clays' duration (so-called abortive pneu- 
monia), which undoubtedly escape observation or are recognized only 
by their critical defervescence. 

Of course, the majority of cases pursue a typical course and are 
readily elicited on careful physical examination. As a rule, ausculta- 
tion discloses harsh breathing all over the chest, and during the first 
stage often distant breathing over the affected area and fine crepita- 
tion along its edges. In the second stage, when the consolidation is 
complete, the breathing is distinctly tubular and the vocal resonance 
bronchial in character (bronchophony). In the third stage, with be- 
ginning resolution, fine crepitant rales (crepitatio redux) return, but 
are often softer in quality. Bronchophony may continue long into con- 
valescence. In the first day or two of the disease the percussion sound 
is usually tympanitic — owing to the presence of some air in the in- 
volved lung, but as the consolidation advances, we readily elicit dul- 
ness or flatness, the experienced hand perceiving also a distinct in- 
creased sense of softness and resistance which is transmitted to the 



322 



DISEASES OF CHILDREN 



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ending by crisis. 





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symptoms in a child two years old. 



percussed finger. Pectoral fremitus is ordinarily not pronounced in 
young children, except when they cry aloud, which act should always 
be encouraged to facilitate the exposition of the physical signs. In 
all stages of pneumonia, inspection reveals more or less marked dysp- 



DISEASES OF THE RESPIRATORY SYSTEM 323 

nea, dilatation of the alaa nasi, and depression of the peripneumonic 
groove with each inspiration. 

Croupous pneumonia generally runs a self -limited course, from five 
to thirteen days or longer, and most frequently terminates by crisis, 
at a time when the disease is at its height. Until then, especially in 
the absence of complications, there is little change in the clinical pic- 
ture of the affection. The fever remains high (104° to 105° F. or 
higher) with slight remissions; the pulse and respiration ratio is greatly 
disturbed, from 1 :2% to 1:2; the cough short, dry and painful, and 
in older children often attended with rusty expectoration; the face is 
pale with a hectic flush and the nose and lips are more or less cyanotic ; 
the urine is scanty, highly colored, rich in salts (with diminution in chlo- 
rides) and occasionally in peptone and acetone; the tongue heavily 
coated, sometimes blackish with its tip red ; and finally the abdomen is 
considerably distended. The child is very restless, listless, tosses from 
side to side, and when able to respond to questions, usually indicates 
the seat of pain somewhere in the abdomen, usually on the side where 
the lung is affected. 

As the crisis approaches and the circulatory difficulties become more 
and more pronounced, the expiratory moan becomes louder and longer, 
the cough more harassing, the breathing more superficial, the pulse 
more rapid and feeble, the thirst more intense, and the sensorium more 
disturbed, — the child lies helpless, often rigid, in a state of apathy, 
frequently interrupted by incoherent outcries and on the verge of col- 
lapse. The change wrought by the establishment of the crisis is cer- 
tainly miraculous.* In but a few minutes the heart's action calms 
down (the pulse is often irregular and very feeble), the breathing be- 
comes slower and deeper, and the patient bathed in perspiration falls 
into a more or less profound sleep, from which he often awakens fully 
refreshed, free from pain and fever (sometimes 2 or 3 degrees below 
normal), ready to take nourishment, and happy to start life anew. 

Unfortunately the typical course of the disease is often marred by 
a number of complications, and even without these, pneumonia may 
prove fatal, the mortality ranging between from 10 to 20 per cent. Not 
rarely, lobar pneumonia terminates by lysis. Defervescence may be 
tardy, the temperature reaching normal by two or three stages. Oc- 
casionally, after an apparently true crisis and durable defervescence, 
recrudescence takes place, the temperature again rising and continu- 
ing for several days. In some instances where the pneumonia is greatly 



*The crisis and resolution of the pneumonic process seems to be due to local biochemic 
changes, in the course of which, as suggested by L,ord (Jour. Exp. Med., October, 1919), the 
acid death point of the pneumococcus is reached. 



324 DISEASES OE CHILDREN 

protracted, the inflammatory process is found to ''creep" from lobe 
to lobe, and may end either in gradual recovery or in unresolved, 
chronic or the so-called caseous pneumonia. Very serious also are the 
cases in which the lung involvement is very extensive (double pneu- 
monia) from the start; where the inflammation, spreading to the 
pleura (pleuropneumonia), gives rise to free effusion which, through 
secondary infection, terminates in pyothorax; and where the pneu- 
monia supervenes upon other infectious diseases (e. g., influenza, diph- 
theria), more especially if it is preceded by cardiac exhaustion from the 
effects of the underlying affection. Occasionally fulminating pneu- 
monia is met with, which is manifested by extreme dyspnea, cyanosis, 
tympanites, high continuous temperature, very rapid and feeble pulse, 
and cerebral symptoms, and ends fatally within two or three days. 
These cases are usually due to mixed infection. 

Complications also substantially mar the prognosis as regards the im- 
mediate and ultimate recovery, meningitis and pericarditis proving 
particularly disastrous. As already stated, pleurisy, with a serous and 
more especially purulent effusion, is more apt to influence the prognosis 
at a later stage. Pneumococcus peritonitis is a very grave complication, 
but recovery may ultimately ensue if the pus in the peritoneal cavity 
becomes encapsulated and finds its way out either through the intes- 
tines or the umbilicus. Suppurative foci (pneumococcic metastases) 
are occasionally encountered in the bones and joints and ordinarily yield 
to surgical procedures. Among other complications, we may also men- 
tion otitis media, which usually clears up with or without perforation. 

The relation between a high leucocytosis and favorable prognosis in 
lobar pneumonia is still subject to controversy. Generally fibrinous 
pneumonia is associated with a high leucocytosis, the proportion of the 
white cells to the red ranging anywhere between 1 to 40 to 1 to 70, which 
is nearly twice as high as in the lobular variety. According to Koplik, 
a very low leucocyte count with marked signs of pneumonia and high 
temperature is a grave prognostic sign. Such cases, however, may re- 
cover. On the other hand, even a high leucocytosis, with extensive in- 
flammation of both lungs, does not prevent a fatal issue. 

Differential Diagnosis. — In the initial stage lobar pneumonia may be 
confounded with bronchopneumonia, pleurisy, meningitis, and appen- 
dicitis; in the second stage with pleurisy with effusion, and in the ab- 
sence of cough and the presence of marked tympanites, with peri- 
tonitis; and in the third stage, especially where resolution is delayed, 
with miliary tuberculosis. Moreover, concurrence of pericarditis may 
occasionally obscure the original disease. Careful attention to the 
pathognomonic signs and symptoms of the different affections ought to 



DISEASES OF THE RESPIRATORY SYSTEM 325 

readily clear up the diagnosis. We must, however, always bear in 
mind the fact that any of the aforementioned diseases may at any 
time complicate the pneumonia. In doubtful cases, a careful differ- 
ential count, and, in hospital practice, an x-ray examination will often 
facilitate the diagnosis. 

Acute Lobar Pneumonia Catarrhal Pneumonia 

Generally a primary disease. Secondary. 

Onset sudden. More gradual. 

High regular fever. Moderate and irregular. 

Inflammatory process localized. More diffuse. 

Physical signs distinct. Indistinct. 

Termination by crisis, the rule. By lysis. 

Acute Lobar Pneumonia Miliary Tuberculosis 

Onset sudden and marked. More gradual and masked. 

Fever high and regular. Very irregular. 

Tuberculin test negative. Positive, as a rule. 

Complement-fixation test negative. Positive in early stage. 

Sputum contains pneumococci. Tubercle bacilli. 

Duration from one to two weeks with From three to six weeks, ending fatally, 
tendency to recovery. 
See also Pleurisy, page 328. 

Treatment. — Pneumonia being a communicable affection, it calls for 
all such hygienic precautions as are ordinarily employed in the pre- 
vention of other contagious and infectious diseases. (See p. 68.) 
The sputum should be collected in small pieces of gauze and destroyed. 

Fresh cool air is the sine qua non in the management of pneumonia. 
It purifies the respiratory tract, eases respiration, facilitates the pul- 
monary circulation, hence relieves and regulates the heart's action, 
reduces temperature, and cheers the patient in those endless, wakeful 
hours, which are so characteristic in pneumonia, and last but not least, 
disinfects the sick room and thus prevents transmission of the disease 
to others, as well as autoinfection of the patient. 

Plenty of pure drinking water is the next most important requisite. 
It should be given ad libitum, unless contraindicated by uncontrollable 
vomiting. Pure water cleanses the mouth, pharynx and alimentary 
canal which in children with pneumonia are usually infected by the large 
quantities of putrid sputum that are swallowed rather than expectorated ; 
it quenches the ever-present agonizing thirst; stimulates expectoration 
and aids in reduction of temperature. 

It is advantageous to administer daily a low enema containing a quart 
or two of warm water with an ounce of bicarbonate of soda — to cleanse 
the bowels and to relieve intestinal fermentation, and also to counteract 
the acetonuria which is quite common in febrile affections. Saline re- 



326 DISEASES OF CHILDREN 

tention enemas (105° F.) may also be given a few times daily to stimu- 
late the action of the kidneys and heart. 

Water should serve as the only antipyretic when reduction of fever 
is indicated, *. e., if above 102° F., and may be administered in the form 
of cold sponges, cold packs, warm baths and, in older children, even 
cool baths followed by brisk friction, if the temperature remains per- 
sistently high. In excessive nerve irritability mustard may be added 
to the warm bath (see "Hydrotherapy," p. 90), although in such 
cases an occasional dose of sodium bromide (5 grains) and pyramidon 
(2 grains) will often act very beneficially. 

Pain and coug;h in pneumonia may be readily relieved by minute doses 
of codeine, with or without sodium salicylate, or by local heat, either 
in the form of a flaxseed and mustard poultice (see p. 318), or cloths 
immersed in warm mustard water, wrung out and covered with oiled 
silk and towel. The mustard cloths may be changed every half hour 
until the pain is relieved. In some cases I observed very good results 
from dry cupping. 

Some authors claim that quinine exerts a specific action in pneumonia. 
It must be pushed to its full physiologic effect — 1 to 2 grains for every 
year of the child's age, every two to four hours. In severe cases, qui- 
nine urea hydrochloride may be administered intramuscularly. 

The heart action requires careful watching. Where the pulse is very 
rapid, the tinctures of digitalis and strophanthus (one drop for every 
year of the child's age) may be given alternately every three hours, while 
when the pulse drops below one hundred per minute, strychnine sul- 
phate (1/200 to 1/100 grain hypodermically) is the remedy of choice. 
The "Murphy drip" is a valuable stimulant to the heart and kidneys. 
For quick stimulation caffeine sodium benzoate (1 to 3 grains every 
six hours) should also be resorted to. The profession is generally in 
favor of sterile camphorated oil (3 grains), although I believe that its 
therapeutic effect is greatly exaggerated. In threatening pulmonary 
edema, nitroglycerine (1/200 grain) may prove efficient. It is well to 
bear in mind, however, that undue overcrowding of stimulants may do 
harm. In cyanosis, oxygen is beneficial. In severe cases of tympanites, 
pituitary solution hypodermically is well worth trying. 

Protracted and unresolved pneumonias often respond promptly to the 
administration of ammonium iodide (1 grain three times a day for every 
year of the child's age). 

The diet should be light and easily digestible, consisting mainly of 
broths, fruit juices, small quantities of plain or fermented milk, albu- 
min water, well diluted wine or cognac. Milk should be dispensed with 
where tympanites is marked. 



DISEASES OF THE RESPIRATORY SYSTEM 327 

The mouth and nasopharynx should be gently cleansed several times 
daily. 

The profession is still at odds over the usefulness of vaccines and se- 
rums in the treatment of pneumonia. If the type of the pneumococcus 
can readily be determined and the homologous serum obtained, it could 
safely be administered, even though we have as yet no positive evidence 
of its specific effect. 

In slow convalescence it is advisable to send the patient to the moun- 
tains or to a mild seashore resort and to administer creosote by mouth 
as well as by inhalation. The syrup iodide of iron and cod liver oil 
are indicated especially in young children. See "Bronchopneumonia". 

Pleuritis 

(Pleurisy. Empyema) 

The pleura, like other serous membranes, may be affected, primarily 
as a result of trauma, or invasion of pathogenic bacteria, such as the 
pneumococcus, streptococcus, the microbe of rheumatism, influenza, etc., 
or secondarily by extension of an inflammation from neighboring struc- 
tures. Primary pleurisy is comparatively rare in young children. The 
secondary variety, however, is quite common in connection with pneu- 
monia, influenza, tuberculosis, acute heart disease, general sepsis, and 
affections of the abdominal organs. 

Pathologically, pleuritis is characterized by congestion and rough- 
ness of either the parietal or visceral layer of the pleura or of both; 
a fibrinous exudation upon the pleura ; in severe cases, a more or less 
large collection of (serous, serosanguinolent, or seropurulent ) fluid be- 
tween the surfaces of the pleura, or between the gaps and meshes of 
the fibrinous exudation. In accordance with the extent and location 
of the pleural effusion, there is more or less severe displacement of the 
contiguous structures. 

I. Dry Pleurisy 

It is quite probable that many cases of dry pleurisy in young chil- 
dren escape detection. This is apt to occur especially in secondary 
pleurisy, where the symptoms of the original disease obscure those 
of the complication. Moreover, little patients often refer the pathog- 
nomonic "stitch pain" to the abdomen instead of to the side. Apart 
from the pain, the subjective symptoms are few and mild. The child 
instinctively abstains from coughing and deep breathing, and like an 
adult lies on the affected side. As a rule, the diagnosis can readily be 
made on hearing the pleuritic friction sound — a dry, crackling sound 



328 DISEASES OF CHILDREN 

on inspiration. The termination of dry pleurisy is either in rapid 
and uneventful recovery (sometimes leaving behind slight pleural thick- 
ening and adhesions) or in the graver form of the malady, i.e., in 
pleurisy with effusion. 

II. Pleurisy With Effusion 

A perceptible pleural effusion, be it composed of serum, blood and 
serum, pus or chyle may generally be recognized by the following 
distinctive features: 

Inspection. — Dyspnea with impairment of movement of the affected 
side. 

In large effusions, fullness of the intercostal spaces and later bulg- 
ing of the affected area of the thoracic wall, and not rarely promi- 
nence of the hypochondrium of the corresponding side. Occasionally, 
enlargement of the subcutaneous veins, and superficial edema. In 
cases of long standing in which effusion undergoes partial or com- 
plete absorption (as well as after operative removal of the fluid), there 
is a lateral curvature of the spine, incurvation of the affected side with 
compensatory bulging of the unaffected side of the chest. 

Palpation.— As compared with the healthy side, there is distention 
of the intercostal spaces on inspiration and diminution of vocal frem- 
itus. In large serous effusion, fluctuation may be perceived by placing 
one finger of one hand in the intercostal space, and with the finger 
of the other hand imparting quick but gentle impulses to the- fluid, in 
the direction of the other finger. 

Auscultation. — Varying with the amount of pleuritic effusion or 
thickening, the respiratory sounds may be diminished or absent over 
the affected side and exaggerated over the healthy portions of the 
lung. Where the effusion is small and the larger bronchi remain open 
for the respiratory current of air, we may hear distant bronchial 
breathing. In rare cases, especially in tuberculous pleuritic effusion, 
the respiratory murmur may simulate cavernous breathing and lead 
to errors in diagnosis, especially if the bronchophony over the com- 
pressed lung is transmitted along the pleuritic adhesions or the chest 
w T all. 

Percussion. — Durness or flatness, corresponding to the amount of 
pleuritic thickening or effusion, over the affected portion of the lung, 
and often tympanitic resonance over the retracted lung tissue. Per- 
cussion must be performed lightly; for in the presence of only a thin 
layer of fluid, forced percussion may elicit the normal resonance of 
the underlying lung. The sense of resistance to the finger is greatly 
increased. Displacement of the neighboring organs. 



DISEASES OF THE RESPIRATORY SYSTEM 329 

Grocco's sign (paravertebral triangle of dulness on the side opposite 
to that of the effusion) is rarely elicited in young children, but is of 
diagnostic value if found. 

Roentgen-Ray Examination. — In the majority of instances an x-ray 
examination aids greatly in localizing the fluid in the thoracic cavity, 
especially when the effusion is scanty and encapsulated or is located 
under the diaphragm (subphrenic abscess). In this connection it is 




Fig. 75. — Grocco's sign of pleurisy with effusion (paravertebral triangle of dulness 
on the side oxixDosite to that of the effusion — G). 

important not to interpret the shadow of gas in the upper gastro- 
intestinal tract as fluid in the thoracic cavity. 

"With, the establishment of the presence of a pleuritic effusion by 
means of the aforementioned physical signs, the nature of the pleu- 
ral fluid content still remains to be determined. In the majority of 
instances this can readily be accomplished by means of exploratory 
puncture. 

Except where the exudate is buried behind a thick pleural mem- 



330 DISEASES OF CHILDREN 

brane or, more rarely, behind tumors of the chest Avail (so that the 
needle does not reach the fluid), or where the pleural content is too 
thick to pass through the needle, exploratory puncture of a pleural 
effusion usually reveals any of the following fluids : serum, serum with 
blood, serum with pus, pure pus, or chyle. In accordance with these 
findings, it is customary to distinguish serous or serofibrinous pleurisy, 
hemorrhagic pleurisy, purulent pleurisy (empyema, pyothorax), and 
chylothorax. 

Serous or Serofibrinous Pleurisy 

The onset may be sudden with vomiting, chills, rise of temperature 
and pain in the side, or, more frequently, insidious, — either as a pri- 
ma^ disease with general malaise, short cough, increasing dyspnea 
and pallor, or as a secondary affection, with accentuation of the symp- 
toms of the primary disease. In acute pleurisies the fever may be 
moderately high and persist for from two to three weeks, and then 
gradually subside, even though the effusion remains. Bilateral pleu- 
risy is almost always tuberculous. Pleurisy, associated with pericar- 
dial or peritoneal symptoms, points to its tuberculous character. In 
young children with a yielding thorax, absorption of large effusions 
is, as stated, almost always associated with contraction of the affected 
half of the chest. The ribs become pressed together, the intercostal 
spaces narrowed, the shoulder blade is drawn nearer the vertebral col- 
umn, and the latter is curved (scoliosis). With complete recovery 
from the disease, the deformity may in some cases gradually disappear. 
In the majority of instances, dulness and suppressed respiratory mur- 
mur continue as a result of pleuritic thickening. 

The prognosis of this form of pleurisy, except that due to tubercu- 
losis, is generally favorable. Occasionally acute pleurisy terminates 
fatally either as a result of a sudden excessive effusion, or of pulmo- 
nary edema, embolism of the pulmonalis or of a cerebral vessel. 

Hemorrhagic and Tuberculous Pleurisies 

In the recent epidemic of influenza quite a number of children pre- 
sented a hemorrhagic exudation in the pleural cavity, in connection 
with bronchopneumonia. In one case, a boy nine years old, we aspi- 
rated over two quarts of hemorrhagic fluid which showed the strep- 
tococcus hemolyticus in pure culture. The patient succumbed to the 
disease within a week notwithstanding early thoracotomy and the ad- 
ministration of autogenous vaccine. 

Protracted cases of pleurisy should always be looked upon with sus- 
picion. In very many instances they are of tuberculous nature. This 



DISEASES OF THE RESPIRATORY SYSTEM 331 

is particularly true of bilateral pleurisy and of that with prolonged 
irregular temperature and serohemorrhagic exudation. It is well to 
remember, however, that a hemorrhagic effusion is sometimes ob- 
served in scorbutic children, and that puncture of a blood vessel or in- 
jury to the diaphragm or liver may bring forth blood in the aspirat- 
ing syringe. In tuberculous pleurisy, before long, other symptoms of 
tuberculosis make their appearance. The presence of the tubercle 
bacillus in the exudate, or, if the lungs are involved, in the sputum, 
and a positive tuberculin test settle the diagnosis. 

Purulent Pleurisy (Empyema, Pyo thorax) 

Owing to the frequency of pneumonias (the principal cause of pleu- 
ritic effusions) in children, empyema is of very common occurrence. 
In the majority of instances the exudation is purulent from the be- 
ginning, more rarely it is serous at first, and, after a protracted course, 
undergoes suppurative transformation, as a result of an endogenous 
infection by the pneumococcus, streptococcus, staphylococcus, or the 
tubercle bacillus. Pyothorax is usually unilateral, and localized on 
the left side more frequently than on the right. Occasionally it is 
bilateral, e. g., in sepsis, pyema, etc. Still more rarely it is multilocular, 
encysted, or interlobular. The amount of pus varies from a few tea- 
spoonfuls to a quart. The exudate may on the first puncture prove to 
be seropurulent ; but, as the disease advances, the purulent character in- 
creases, becoming greenish-yellow in color and sometimes fetid in odor. 
It may be feculent, indicating some connection with the abdominal con- 
tents. 

Pyothorax may also develop primarily as a result of trauma. As 
a rule, however, it is met secondarily to inflammatory, especially sup- 
purative, processes of the thoracic and abdominal organs, of the joints, 
ribs and vertebrae, or in association with general sepsis. As a sequal 
or complication of thoracic or abdominal diseases, empyema usually 
sets in very insidiously, and may even remain latent for some time until 
either the effusion is so large as to cause bulging of the affected side 
of the chest, or to be discovered accidentally during a routine examination 
for some other ailment. The onset is more acute in cases due to 
trauma, necrosis of the neighboring bony structures, exanthematous 
diseases, or in sudden rupture into the pleural cavity of abscesses of the 
neighboring organs {e.g., hepatic, perinephritic, etc.). In such cases 
the symptoms resemble those of acute serofibrinous pleurisy, except 
that the temperature is higher and more irregular and emaciation 
and exhaustion are more pronounced. 



!32 



DISEASES OF CHILDREN 



Aside from the physical signs already enumerated, empyema com- 
plicating pneumonia may generally be suspected where resolution is 
delayed and the temperature continues high and irregular and is ac- 
companied by sweating. In such cases, even in the absence of pathog- 
nomonic physical signs, Eoentgen-ray examination and exploratory 
puncture should not be long delayed. 




Fig. 76. — Extensive right empyema in a child four years old. 



With early operative treatment empyema in children usually ter- 
minates in recovery. If let alone, the abscess may rupture sponta- 
neously either in the lungs or externally through the chest wall — empy- 
ema necessitatis. The point of external rupture is usually found in 
the vicinity of the sternum, where the chest wall offers least resist- 
ance. If the rupture is into a bronchus, a very large expectoration of 



DISEASES OF THE RESPIRATORY SYSTEM 333 

pus occurs suddenly. In these cases there is always danger of pyo- 
pneumothorax. In another group of cases the pus may by inspissation 
lead to caseous residues and to fatal issue from gradual exhaustion 
or from complications, such as tuberculosis, amyloid degeneration, 
etc. 

Chylous Pleuritis (Chylothorax) 

Genuine chylous effusion in the thorax is an exceedingly rare con- 
dition. More frequently we meet with other milky effusions. — chyli- 
form, latescent (nonchylous). True chylous effusion is the result of 
injury or obstruction of the thoracic duct, allowing the escape of chyle 
either directly through an opening in the wall of the duct or indirectly 
by transudation. 

The differential diagnosis between the different varieties of pleurisy 
can readily be made by means of an exploratory puncture, and by 
ehemic, bacteriologic, and micrcscopic examinations of the fluid obtained. 
Bilateral (usually tuberculous) pleurisy may be confounded with hy- 
drothorax. The latter condition, however, is associated with anasarca, 
consecutive to heart or kidney disease, and generally runs an afeb- 
rile course. Left-sided pleurisy may be differentiated from pericar- 
ditis by the absence of heart symptoms (triangular heart dullness) 
in the former, and of lung symptoms in the latter. The synchro- 
nous occurrence of both of these diseases, however, should be borne 
in mind. Right-sided, purulent pleurisy may be mistaken for an 
abscess or hydatid cyst of the liver. Careful examination will elicit 
the following differential points: in liver affections the midaxillary 
line forms the highest point of dulness ; there are fluctuation, local 
tenderness and icterus ; in pleurisy with effusion the last-named signs 
are absent and the midaxillary line forms the lowest point of dulness. 
Furthermore, in pleurisy aspiration brings forth serum, blood or pus : 
in hydatid cyst of the liver, a nonalbuminous fluid with "hooklets." 

The differentiation between lobar pneumonia and pleurisy is not 
always easy, since both diseases often coexist. In the latter event, how- 
ever, exploratory puncture will readily clear up the diagnosis. 

Pneumonia Pleurisy with Effusion 

Dulness (late). Flatness (early). 

Temperature high. Low (in absence of pus). 

Pulse-respiration ratio -greatly disturbed. Xot so. 

Bronchial breathing, bronchophony. Suppressed breathing. 

Vocal fremitus and resonance increased. Diminished. 

Treatment. — During the acute stage, keep the patient in bed. Limit 
the supply of fluids (in older children a semisolid diet, consisting 



334 DISEASES OF CHILDREN 

principally of cereals, concentrated broths, beef juice, soft-boiled eggs, 
etc.). Relieve pain by salicylates, perhaps with some opiate internally; 
by strapping of the chest; flaxseed poultices, or the following oint- 
ment 

Tr. Iodini 

01. Gaultherias 
01. Terebinthae 

Guaiacolis 

Ielitliyolis aa. 3 i 4.0 

Liq. Vasdini q. s. ad f % ii 60.0 

M. 

S. — Paint the affected parts twice a day, cover with absorbent 
cotton and bandage. 

Should the exudation increase to such an extent as to greatly inter- 
fere with breathing, aspirate with Potain's aspirator and follow it 
up with the local application and strapping, and the administration 
of sodium iodide and infusion digitalis — the iodide to promote absorp- 
tion of the fluid, the digitalis to counteract the interference with the 
heart action by the exudate, as well as to stimulate diuresis. These 
latter procedures (except aspiration) are indicated also in cases run- 
ning a protracted course, even without a large effusion. Aspiration 
should be practised in tuberculous pleurisy only to relieve the res- 
piratory difficulty, and in chylothorax, both as a palliative as well as 
a curative measure. 

As soon as pyothorax is detected, an immediate operation for re- 
moval of the pus is imperative. To wait for eventual spontaneous 
evacuation of the pus through the lungs or externally, is hazardous, 
principally because of the supervening, often fatal, exhaustion, and 
of the clanger of complicating pyopneumothorax, an incurable fistula, 
or caseous degeneration. It is to be noted, however, that in acutely 
developing influenza empyema aspiration is to be preferred to thorac- 
otomy until the active pulmonary inflammation has subsided. In tuber- 
culous empyema, surgical interference is indicated only in threatening 
suffocation, or grave cardiac embarrassment. Empyema of brief dura- 
tion with readily flowing pus usually does well with a free incision 
into one of the intercostal spaces and good drainage. On the other 
hand, cases of long standing or those with inspissated pus should be 
treated by resection of a rib, in order to permit free escape of the pus. 
The disfigurement after such operation in children is comparatively 
slight, and many cases of regeneration of even several ribs are on 
record. If the empyema is bilateral, it is advisable to operate at sepa- 
rate sittings. 



DISEASES OF THE RESPIRATORY SYSTEM 



335 




Fig. 77. — Same case as Fig. 76 three weeks later after resection of second and third 
ribs. Note clearing of right lung. 

Patients recovering from pleurisy, with or without effusion, should 
have plenty of outdoor air, preferably in the country, seashore or 
mountains. Older children will derive great benefit from horseback 
riding. For expansion of the retracted lung after a protracted at- 
tack of pleurisy with effusion, systematic breathing exercises and cold 
sponging of the chest or cold affusions are very useful. 



336 



DISEASES OF CHILDREN 




Fig. 78. — Same case as Fig. 76 two months later. Right lung field almost clear. 
Note retraction of chest wall and secondary scoliosis. 



The importance of wholesome feeding should not be underestimated. 
Iron, the hypophosphites, cod liver oil, and extract of malt are helpful 
to effect the cure. 

Prompt attention to suppurative foci (e.g., necrosis of ribs or ver- 
tebrae) and early treatment of pneumonia by fresh air will frequently 
prevent empyema. 



DISEASES OF THE RESPIRATORY SYSTEM 



337 



Asthma 
The pathogenesis of asthma in children is essentially the same as 
that in adults — stenosis of the lumen of the bronchial tubes. The 
stenosis mar be brought about either by a spasmodic contraction of 
the muscle fibers of the bronchioles, or by vasomotor turgescence and 
swelling of the bronchial mucosa. Children suffering from asthma 
usually present an hereditary tendency toward the disease, a suscepti- 
bility to protracted irritations of the nasopharyngeal, laryngeal, and 
bronchial mucous membranes (exudative diathesis, q.v.,) or a history 
of pertussis, bronchopneumonia or chronic bronchitis. In many instances 
local causes, such as adenoids, deformities of the nasopharynx, persistent 
thymus, etc., are met with, and some cases are traceable to reflex causes, 
e.g., indigestion (see "Allergy," p. 87). Asthma in young children 
seems also to be correlated to eczema. In one marked case (two-year- 
old baby) under my observation, recurrence of the asthmatic attack 
coincided regularly with the subsidence or marked improvement of the 
eczematous eruption. Symptomatic asthma is occasionally based upon 
liay fever — resulting from the action of pollen of certain plants upon 
the mucous membrane of the nasopharynx — and, finally, an asthmatic 
attack is sometimes a manifestation of hysteria. 



Classification of Causes of Bronchial Asthma. 
broxchial asthma ( walker) 

















NO. SENSITIVE 


TO 


EH < 

W. & 












PROTEIN IN 




O B 

Xfl 


P3 w 








< 




< 


^^ 


Eh <j 


W M 


W w. 


fa En 


fa Ph 




a 


jjq 


< 


M < 


o < 


M E 


° a 




w 


w 




. u 


§ ° 


u 


gg 


HI 


S M 


© 


H 


j 


H C 




(3 


P3 & 




O 


O 


J 


o 


5 fe 


H fa 


P w 


fa w 


^ 3 


o 




o 


■«! 


£ O 


Ch o 


Y-, m 


Oh CQ 


<1 W 


fa 


pq 


Ph 


Under two years . . 


34 


9.0 


28 


-83 


19 


23 


5 


15 


Between 


2— 5.. 


30 


7.5 


27 


90 


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338 DISEASES OF CHILDREN 

With these etiologic factors in view, the subdivision of asthma into 
true and false is quite justified. Clinically the two varieties differ in 
that genuine asthma is invariab^ associated with chronic bronchial 
catarrh, hence, is based upon a pathologic entity, and is of longer dura- 
tion than false asthma. There is nothing characteristic about the ca- 
tarrh. The paroxysm usually comes on at night. The child coughs, 
is a little wheezy, and in a few hours the typical attack is in full sway. 
The latter consists of extreme dyspnea, inspiratory as well as expira- 
tory, anxious expression of the face, congested eyes, cyanosis or pallor, 
cold extremities, restlessness and prostration. The patient is usually 
relieved by sitting up in bed. Auscultation of the chest reveals sonor- 
ous and sibilant rales, wheezing, squeaking, and whistling respiration. 
These sounds are often audible at a distance. As the attack subsides 
the breathing becomes less and less noisy, less labored, and less rapid. 

There may be complete apyrexia, or a rise of temperature of from 
two to three degrees. The respiratory rate may be anywhere from 40 
to 80 and the pulse 150 or over. During the height of the paroxysm 
there is marked eosinophilia, and where expectoration is abundant 
Curschman's spirals and Charcot-Leyden's crystals are found in the 
more or less glairy mucus. Toward the end of the attack the thorax may 
appear barrel-shaped; but unless the asthma is chronic in nature and 
characterized by prolonged attacks, the emphysematous deformity of 
the chest is usually only temporary. The attack may last minutes, hours, 
or days, with temporary remissions, but after abatement of the paroxysm 
the child is apparently in good health except for the bronchial catarrh. 
In genuine asthma, exacerbations usually occur in the fall and spring, 
when the sudden atmospheric changes contribute to catarrh of the mu- 
cous membrane of the respiratory tract. On the other hand, paroxysms 
of false, spasmodic asthma may occur at any time when the exciting 
cause, e. g., indigestion, sudden fright, etc., presents itself. 

As a rule, asthma is not fatal per se. Delicate infants, however, may 
succumb during a severe attack, as a result of suffocation, or after fre- 
quently repeated attacks, as a result of emphysema, cardiac dilatation, 
or even cerebral hemorrhage. 

Treatment. — The importance of curing the disease at its very in- 
ception or, at least, preventing or mitigating the paroxysm, is obvious. 
A cure can be effected, if the cause can be found and corrected. At- 
tention to abnormalities of the nose and throat is especially fruitful 
in this direction. Children having an asthmatic or arthritic history 
should be given particular care in the Avay of preventing colds and 
coughs, overfeeding, exposure to unhealthy surroundings, miasmatic 



DISEASES OF THE RESPIRATORY SYSTEM 339 

affections, undue excitement, etc. An attack may, in a way, be aborted 
by early administration, preferably hypodermically, of atropine, 1/2000 
grain and morphine 1/60 grain or adrenalin (5 to 10 minims), and 
by apomorpliine 1/50 to 1/100 grain, repeated, if necessary, after half 
an hour. The latter drug is especially efficient in "dyspeptic" or 
" hysterical" asthma. A few drops of a suprarenal gland solution in- 
stilled several times a day into the nose sometimes act admirably. If 
the paroxysm continues we may resort to the following combination : 

B; Potassii Bromicli 3 ss 2.00 

Tr. Hyoscyami 

Ext. Aspidospermse (Quebracho) 
Ext. Grindeliae Bobustae aa f 3 i 4.00 

Syr. Pruni Virginianae q. s. ad f g ii 60.00 

M. 

S. — One teaspoonful every three hours; for a 
child five years old. 

A course of syrup of the iodide of iron with cod liver oil is very 
useful in all cases, and change of climate, to the seashore or inland, 
is sometimes effective in enhancing a permanent cure. In protracted 
cases a meat and milk-free diet maj T be tried. The patient is fed ex- 
clusively on well-cooked cereals — without milk or sugar — and vege- 
tables. Sweet butter is added to make the food more palatable. 

In treating asthma we should always bear in mind that asthma-like 
attacks are observed as a manifestation of a large thymus, spasmo- 
philia, malaria, or heart and kidney disease, calling for specific thera- 
peutic measures to remedy the underlying affections. 

Emphysema Pulmonum 

Abnormal distention of the lungs with air occurs as a result of 
forced inspiration, e. g., in stenosis of the larynx (croup) or bronchioles 
(asthma), whooping cough, in bronchitis or bronchopneumonia with 
violent coughing, etc., or from forcible expiration, e. g., cornet playing. 
Owing to the great elasticity of the puerile lung and its tendency to rapid 
adjustment, emphysema as a permanent affection is rarely observed in 
children. If it does occur, it is most frequently limited to the apices 
and the anterior borders of the lungs. Exceptionally the emphysema is 
disseminated throughout the entire lung. In this event the symptoms 
are practically the same as those in the adult — namely, exaggerated 
resonance on percussion, diminution of relative cardiac dulness, dyspnea, 



340 DISEASES OF CHILDREN 

fulness of the upper portion of thorax or barrel-shaped chest, and pro- 
longed incomplete expiration. In cases of long standing there is con- 
secutive involvement of the heart — usually dilatation of the right heart, 
with or without hypertrophy. 

The treatment consists, in addition to removal of the cause chiefly of 
change of air (mountains), and light breathing exercises. 

Bronchiectasis 

Bronchial dilatation is not very uncommon in children, but as it 
usually forms a sequel of respiratory diseases (unresolved pneumonia) 
with violent coughing, or aspiration of foreign bodies into a bronchus, 
its presence is frequently obscured by the symptomatology of the 
preceding affection. Cases of congenital bronchiectasis are on record. 

The dilatation of the bronchus may be cylindrical or sacculated, 
and is almost always associated with peribronchial sclerosis (pul- 
monary contraction), and occasionally with emphysema. 

There are no pathognomonic signs of this affection, except, perhaps, 
the copious morning expectoration of greenish-yellow, often fetid, 
purulent mucus, which on standing separates into an upper layer of 
serum and a lower of pus. Auscultation of the affected part of the 
chest reveals abundant moist rales, and, if the bronchiectatic cavities 
lie near the chest wall, cavernous signs, which greatly resemble those 
of tuberculous cavities. In bronchiectasis, however, the sputum is 
free from tubercle bacilli and the course is usually afebrile and often 
remittent — the child often doing well for weeks. In cases of long 
standing, there is usually clubbing of the fingers and deformity of the 
chest. An extensive bronchiectasis may often be revealed by a roentgen- 
ray picture. 

Treatment. — Eelative recoveries from this affection have been re- 
ported particularly recently by surgeons who do not hesitate to per- 
form pneumonectomy. Otherwise the majority of cases are incurable, 
and after a shorter or longer (years) course the patients succumb 
to intercurrent diseases, such as pneumonia, miliary tuberculosis, or 
pulmonary gangrene. 

The medical treatment is principally hygienic and prophylactic : 
wholesome food, tonics, breathing exercises, inhalation of warm va- 
pors with eucalyptus, creosote, or turpentine, or of oxygen, residence in 
a high, dry region. 

To facilitate emptying the dilated bronchi of their mucopurulent 
content, gentle inversion of the little patient a few times a day proves 
useful. 



DISEASES OF THE RESPIRATORY SYSTEM 341 

Pulmonary Gangrene 

Gangrene of the lungs is not rarely a sequel of pneumonia, phthisis, 
grave exanthematous diseases, gangrenous processes of the mncous 




Fig. 79. — Pneumothorax (posterior view). Note compression of lungs and disloca- 
tion of heart. 



membrane or of the skin, foreign bodies in the air passages (entrance 
of bits of food), etc. The symptomatology of this affection is ill 



342 



DISEASES OF CHILDREN 



defined. In older children, as in adults, the macro- and micro-scopic 
appearances of the expectoration (upper layer, mucopurulent; middle, 
serous; lower, almost wholly of pus; remnants of lung tissue and plugs 
containing needles of fat, acids and detritus) are very helpful in the 
diagnosis. On the other hand, in infants, chief reliance must be placed 
upon the general cachectic condition of the patient, the coexistence of 
gangrene of the mouth, throat or vulva, the frequent occurrence of 




Fig. 80. — Pneumoliypoderma (emphysema cutis) in a girl five years old complicatin< 

measles with pneumonia. 



hemoptysis (absence of tubercle bacilli), fetid diarrhea, and foul breath. 
The cough is usually spasmodic. 

The course of the disease is comparatively rapid, fatal termination 
usually occurring within a few weeks, either from gradual loss of 
strength or from complications, such as hemoptysis, pneumothorax, 
thrombosis, or cerebral abscess. 

The treatment is symptomatic — tonics, inhalation of antiseptics, and, 
if the gangrenous process is accessible, surgical intervention. 



DISEASES OF THE RESPIRATORY SYSTEM 



343 



Pneumothorax, Hemopneumothorax, Pyopneumothorax 

These conditions occur principally as a result of traumatism (frac- 
ture of a rib or clavicle), laceration of the lungs from violent cough- 
ing or by foreign bodies, perforation of the lungs through empyema, 
gangrene and similar destructive processes. 

The symptomatology is the same as in adults: sudden severe dysp- 
nea, bulging of the affected side, tympanitic percussion sounds. When 
effusion occurs, there is hyperresonance over the upper portion of the 





mm 


v mm ] 
1 EJ 


1 

Hub . #. . w k 



Fig. 81. — Same case as Fig. 80 six weeks later. 



affected part of the chest above the line of effusion and dulness or flat- 
ness over the seat of effusion. Succussion gives rise to splashing 
sounds. The diagnosis can readily be corroborated by thoracentesis and 
Roentgenograms. 

The treatment consists of the administration of opiates for the pain 
and aspiration (of air or fluid) to relieve the intense dyspnea in addi- 
tion to attention to the primary cause. 



344 DISEASES OF CHILDREN 

Pneumohypoderma* 

(Emphysema Cutis) 

Entrance of air into the subcutaneous areolar tissue ordinarily results 
from rupture or laceration of the pulmonary alveoli or bronchi during 
violent coughing or dyspnea (e. g., in pertussis, measles, phthisis pul- 
monum), or secondarily to suppurative or caseous processes in the lungs. 
It is occasionally observed in connection with traumatic pneumothorax, 
and after tracheotomy and intubation. The air inflation may remain 
limited to the neck and face or spread over the entire upper half of 
the body, and exceptionally also to the lower half. 

Pneumohypoderma can be detected by the distinct crackling or purr- 
ing sensation imparted to the examining finger, and can readily be dif- 
ferentiated from anasarca by the absence of pitting on pressure. In 
severe cases the distention of the skin imparts to the palpating finger the 
sensation very much akin to that experienced when pressing upon a 
tensely inflated toy balloon. 

If the immediate cause can be promptly arrested, e. g., violent cough, 
by means of morphine, reabsorption of the air usually occurs within a 
few weeks. Kapidly fatal cases, however, are on record. 



*The new term is suggested because it locales the exact seat of the trouble; it also helps to 
distinguish this condition from ''surgical emphysema," which is produced by gasogenic bacteria. 



CHAPTER VII 
SPECIFIC COMMUNICABLE DISEASES 

Influenza 

(The Grip, The Flu, Spanish Influenza) 

Influenza is an acute, highly communicable, endemic and epidemic 
disease, characterized by a variable group of respiratory, gastric and 
nervous phenomena, intense prostration and great tendency to grave 
complications and sequela?. 

Until the most recent epidemic, the bacillus of Pfeiffer was looked 
upon as the indisputable cause of this affection; since then, however, 
a great deal of evidence to the contrary has accumulated, which sheds 
doubt on its specificity. Col. Victor C. Vaughan, whose scientific and 
practical experience with the grip epidemic has been almost unlimited, 
does not hesitate to state that to him the evidence that the Pfeiffer 
bacillus as the cause of influenza is not at all convincing for the fol- 
lowing reasons.* "In the first place, it is by no means constantly found 
in influenza or its sequels. In the second place, it is often even with 
greater frequency found in other diseases than it is in influenza. In 
the third place, influenza is characterized by a marked leucopenia, 
whereas injection of the Pfeiffer bacillus causes a leucocytosis — just 
the opposite!" Moreover, repeated experiments to communicate the 
disease by direct inoculation (subcutaneously, by the nose and throat 
and swallowing of influenza sputum) proved negative. On the other 
hand, some authorities maintain that the influenza bacillus is demon- 
strable in the majority of cases of influenza, but that it plays an un- 
important part in the secondary, so often fatal, infections, the latter 
developing chiefly as the result of a characteristic violent reduction 
of the resisting power of the tissues, which offer the pneumococci, 
streptococci (hemolyticus and viridans), Friedlander bacillus, staphy- 
lococcus aureus and micrococcus catarrhalis a favorable culture me- 
dium to become markedly pathogenic! 



*Jour. Am. Med. Assn., Dec. 21, 1918. 

tBacteriologic examination of the pleural fluid removed surgically and sent to the laboratory 
together with that encountered at necropsy, revealed streptococci in most instances, occasionally 
Staphylococcus aureus and pneumococci. Bacteriologic examination of the pus in the intra- 
pulmonary abscesses almost invariably yielded a pure growth of Streptococcus hemolyticus, but 
occasionally Staphylococcus aureus. In three cases, Streptococcus hemolyticus was isolated in 
pure culture from the blood. In the pneumonic exudates themselves, the prevailing microorgan- 
ism was a streptococcus. In occasional instances, influenza bacilli and pneumococci were iso- 
lated in combination with one another or with streptococci. There were three cases in which 

345 



346 



nisi: asks of children 



The pathology of the disease differs with every epidemic as well as 
with each individual attack. In cases of moderate severity the lining 
membrane of the rhinopharynx and lower portions of the respiratory 
tract are hyperemic and sparingly covered by a grayish, often very thick, 
deposit. The bronchi and bronchioles are filled with a mucopurulent 
secretion containing the aforementioned bacteria. Here and there the 
pulmonary alveoli are involved. In severe cases the inflammation ex- 
tends throughout the entire lung and pleura. In the recent epidemic 








■*%&&*& 



Fig. 82. — Section of lung of epidemic influenza in a young infant showing conges- 
tion of the blood vessels in the pleura and hemorrhages just beneath the pleural sur- 
face. (Drs. Martha Wollstein and A. Goldbloom.) 



of the so-called Spanish influenza, Oberndorfer,* among many other 
clinicians and pathologists, found the following pathologic entity: 



massive portions of a lobe were consolidated in such fashion as to resemble ordinary croupous 
pneumonia. In all of these the exudate was sticky. In two, Bacillus mucosus-capsulattts was 
isolated, in the other Streptococcus mucosus. In three other cases, streptococci were isolated 
from the blood during life; and all of them, at necropsy, presented abscesses of the lungs. 
(Symmers, Dimerstein and Frost, Jour, Am. Med. Assn., July, 1920.) 

*Ueber die Pathologische Anatomie der Influenzaartigen Epidemie (Munchen. med. 
Wchnschr., Vol. lxv, p. 810). 



SPECIFIC COMMUNICABLE DISEASES 3-17 

In the initial stage of the affection of the lungs, namely, when only small foci 
without any great reaction in the immediate neighborhood are observed, the most 
striking findings were small, bean-sized hemorrhages projecting into the lung tissue. 
As a next step there followed a firmer infiltration of the parenchyma, the nodules 
sitting subpleurally and raising the pleura in consequence. A whole scale of inter- 
mediate formations lay between these small nodules and large hemorrhagic tuberous 
infiltrations; all possible gradations were observed from simple blood extravasa- 
tions into the lung tissue, still containing air, to firm, almost dry, infarct-like hem- 
orrhages of a bluish-black tinge. These extensive infiltrations were of the same shape 
as the usual pulmonary hemorrhagic infarcts, namely, they had the form of a wedge 
with its base resting on the pleura, thus clearly indicating an intimate relationship 
with the vascular system of the lungs. In this purely hemorrhagic initial stage no 
thrombi were ever found in these arteries, the extravasation of red cells being ob- 
viously due to an abnormal permeability of certain portions of the arterial system. 

The second stage was characterized by exudative pneumonic processes combined 
with hemorrhages. The picture varied considerably at times. There may be a 
true croupous hepatization of lobular, or even lobar, extent, both red and gray, 
though the tinge was usually brownish and not as a rule very distinct. These pneu- 
monic infiltrations usually embraced in their center circumscribed hemorrhages. 
The surface on section was not dry, being covered by a slimy, dirty coating, thus 
resembling a picture of Friedlander ?s pneumonia. The pneumonic foci were some- 
times flattened out at the ends into yellowish white wedge-shaped strictures corre- 
sponding to anemic infarcts both in form and color. These often became the seat 
of gangrene or suppuration, the pleura also being obviously involved in the process. 
In the majority of cases it was a catarrhal and desquamative succulent infiltration 
rather than a fibrinous exudation, but almost always severely complicated by sup- 
puration. 

The bronchi were filled with pus already in the first stage, the smaller branches 
containing thin fluid, though at times dried-up exudates formed firm plugs occlud- 
ing the lumen of the bronchioli. This purulent bronchitis had as its consequence an 
extensive bronchiectasis with the bronchi distended cylindrically. The bronchi and 
their blood vessels were often surrounded by purulent infiltrations originating from 
the lymphatic system. In other cases, again, there were seen on section enormous 
numbers of minute abscesses surrounded by hemorrhages, the suppuration being ob- 
viously hematogenic in origin. These minute abscesses often became confluent, 
thus ending up by the formation of large caverns of pus. 

The pleura participated in the process. The first signs consisted in punctiform 
hemorrhages, or ecchymoses; serous exudations followed next, and, as often as not, 
empyemas completed the picture. As a rule, one side only Avas affected. Pericardi- 
tis was a natural consequence of pleuritis. There were no gross changes in the 
heart save for some thickening of the arteries of the lung hilum. Occasionally in- 
cipient endocarditis was encountered. 

The larynx and the upper third of the trachea showed no involvement in the 
process. The lower portion, however, was the seat of an intense mucopurulent 
exudation, which in many cases assumed a fibrinous character, with the consequent 
formation of extensive pseudomembranes in the lower trachea and down into the 
bronchi. Sometimes edema of the epiglottis was observed. 

A striking feature was presented by the hyperplastic condition of the lymphatic 
apparatus of the tongue and the tracheal ring. The thymus was well preserved, 
the cervical and axillary, but not the inguinal, glands were enlarged. 



348 



DISEASES OF CHILDREN 



In the postmortem examination of 18 infants, Drs. Wollstein and 
Goldbloom* found also subcapsular hemorrhages over the thymus, thy- 
roid and suprarenals, and also small hemorrhages within the swollen 
bronchial and mediastinal lymph nodes. 

The alimentary tract rarely escapes infection especially in young 
children. The spleen is enlarged, sometimes a septic spleen tumor be- 
ing found. The liver is but seldom involved. The kidneys show a 
general hyperemia. In the brain and the meninges there is marked 




Fig. 83. — Section of lung of epidemic influenza in a young infant showing sup- 
purative bronchitis and areas of pneumonia about the bronchi. The exudate is 
chiefly polynuclear in character. (Drs. Martha Wollstein and A. Goldbloom.) 



vasodilatation, but no meningitis. Punctiform hemorrhages are met 
in different parts of the encephalon, and cases are on record in which 
the ventricles were filled with blood and pus. There are also hemor- 
rhages in the heart valves, with a consequent displacement of the 
fibers and damage to the endothelium; thus, no definite endocarditis, 



*Am. Jour. Dis. Children, March, 1919. 



SPECIFIC COMMUNICABLE DISEASES 349 

but lesions which facilitate the development of a secondary micotic 
endocarditis. 

The essence of the whole pathologic picture consists, therefore, in 
the abundance of hemorrhages seen in the mucous and serous mem- 
branes, in the respiratory tract, and in the lungs, Avhich indicate a 
damaged condition of the capillary vascular system. The whole process 
seems to be primarily a bacteremia localized in particular in the pul- 
monary blood vessels. From a purely anatomic point of view the con- 
dition bears many points of resemblance with pneumonic plague, 
though there is no indication as to an entry of the virus through defi- 
nite lymphatic channels. Furthermore, as already stated, the true 
nature of the virus, the primary infecting agent, is still undiscovered. 

Clinical Course. — No age is exempt from this affection, and one at- 
tack neither predisposes nor immunizes for any length of time against 
another one. The incubation period varies from two to five days. 
The onset is usually sudden or may be preceded by a few mild prodro- 
mata common to all febrile affections. The previous attempts to clas- 
sify the grip into three distinct types, — namely, catarrhal, gastric, 
and nervous, was based upon an erroneous conception of the pathology 
of the disease. It is the multiplicity of the lesions and the complexity 
of the symptoms which are the characteristics of influenza. Thus, the 
child sneezes, coughs, has no appetite, vomits, complains of pain in 
the entire body, especially in the throat, head, eyes and lower extremi- 
ties, has high fever, is very restless or lies exhausted in a semistupor 
— an indefinite group of symptoms which is met with in quite a num- 
ber of acute febrile affections. 

The onset is usually sudden, sometimes preceded by signs of fatigue, 
headache, and chilliness. This is followed by an abrupt rise of tem- 
perature up to 104° F. or higher, which usually continues during the 
entire course of the disease. The throat is deep red in color, and the 
tonsils and fauces are often covered with glairy mucus and occasion- 
ally with a yellowish- white irregular deposit, The cough is dry, harsh 
and painful, especially over the region of the sternum, and large, soft 
or dry sibilant rales are heard over the greater portion of the thorax. 
In infants particularly, there are more or less pronounced manifesta- 
tions also of the alimentary tract. The baby vomits, refuses food, cries 
from abdominal pain, and has an increased number of foul smelling, 
variously colored, thin evacuations. In older children the gastroin- 
testinal symptoms are usually limited to anorexia, tympanites and 
occasionally constipation. The nervous system is almost invariably 
implicated in the grippel process. Among the characteristic nervous 
phenomena we may mention, in the order of their frequency, hyper- 



350 



DISEASES OF CHILDREN 



esthesia, headache, somnolence, insomnia, vertigo, and convulsions. The 
child cries when it is being lifted or moved about in bed. The pain 
in the head, neck, trunk and extremities often keeps the little pa- 
tient in a position closely resembling- opisthotonos, and if accompanied 
by convulsions, one is often tempted to diagnose the symptom complex 
as meningitis. The somnolence is frequently profound. One baby un- 
der observation dozed for six days, awakening with a fit of crying 
when disturbed even for nursing. On the other hand, some children 
keep awake for several days in succession, notwithstanding the admin- 
istration of hypnotics. Vertigo in infants usually escapes our notice; 
in those able to hold up their heads, it is manifested by the latter 
dropping forward or swaying in different directions. The eyelids 



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Fig. 84. — Fever curve of atypical influenza in a baby fourteen 



months old. 



droop, the face turns pale and vomiting supervenes. Older children 
invariably complain of this miserable feeling, and find difficulty in 
holding their heads erect. 

The blood shows a striking leucopenia, even in the presence of com- 
plicating pneumonia. According to L. A. Conner, a leucopenia of from 
2,000 to 3,000 white blood cells per cubic millimeter is by no means 
uncommon. Leukocyte counts were made by Montgomery and Dunham* 
in thirty cases of influenza occurring in infants and children less than 
12 years of age. They found that the tendency in uncomplicated in- 



*Am. Jour. Dis. Child. Vol. 18, No. 3. 



SPECIFIC COMMUNICABLE DISEASES 



351 



fiucnza in infants and children is toward a leukopenia, rather than a 
leukocytosis. There is a tendency to a slight leukocytosis in compli- 
cating pneumonia. In this series, in all pneumonia cases resulting 
fatally, the leukocyte counts were under 10,000. The prognosis, in 
general, is better in pneumonia cases which exhibit a leukocytosis. 
Differential counts have shown: (a) a tremendous variation in the 




Fig. 85. — Paralysis of N. abducens, with convergent strabismus and facial paralysis 
following postinfluenzal encephalitis. Her mentality remained greatly affected. 



differential formula, and (&) nothing sufficiently constant to be of clini- 
cal aid in diagnosis or prognosis. 

Influenza shows a peculiar predilection for hemorrhagic processes, 
such as epistaxis, hemorrhage from the bowels, in the skin, the ears 
and pleural cavity, and in the urinary tract. In a contribution to the 
study of this disease (N. Y. Med. Jour., June 30, 1900), I called atten- 
tion to the concurrence of hemorrhagic encephalitis during the course 
of the grip, and have since had occasion to observe several such cases. 
This form of encephalitis seems to be identical with the so-called leth- 



352 DISEASES OF CHILDREN 

argic encephalitis (see p. 624) so frequently noted during the recent 
influenza epidemic and thereafter. One boy, eight years old, under my 
care, died from this complication twelve hours after its onset. As a 
rule, the mortality in these cases is rather low. Of 8 cases recorded by 
II. Herman 1 none died but 2 of them remained imbeciles. Similar cases 
were recorded by me 2 several years ago. 

In uncomplicated sporadic cases the tendency of influenza is toward 
rapid convalescence and recovery, especially in strong children and those 
free from hereditary and acquired encumbrances. Unfortunately, how- 
ever, influenza, by reducing the power of resistance of the patient, predis- 
poses to prolific, often fatal, complications. In some epidemics ear affec- 
tions predominate, in others cerebrospinal disorders, and in others again, 
as it happened in the last epidemic, respiratory affections devastate the 
world. The so-called ' ' influenza pneumonia ' ' usually sets in the second or 
third day of the disease, at a time when the influenza proper seems on the 
wane. The patient, especially if an infant, begins to vomit again, and 
shows definite signs of being ill at ease, without being able to locate the 
seat of his discomfort. The cough loosens, but the dj^spnea increases and 
the heart beat, as a rule, slows down and gives the impression of being 
more steady in quality. At this stage careful physical examination 
of the thorax often utterly fails to elicit any signs of pneumonia, ex- 
cept, perhaps, exaggerated breathing over the posterior portions of 
the lower lobes. On many occasions I was most painfully surprised 
to find what at first seemed to be a simple bronchitis, within but a few 
hours transformed into double fatal pneumonia. Similar to erysipelas 
of the skin, the inflammatory process of influenza seems rapidly to 
spread by contiguity from structure to structure and from one organ 
to the other, so that on every examination of the patient a newly dis- 
eased focus is detected. Cyanosis,* delirium and coma generally pre- 
cede the fatal issue, which usually takes place within three to five 
days. Those children who withstand the exhausting effects of the 
violent acute stage often survive, even though convalescence and re- 
covery may very frequently be markedly delayed by additional grave 
complications and sequels. As already stated, the pleura very rarely 
escapes involvement. The pleuritic effusion is not infrequently hemor- 
rhagic or purulent in character from the start and accumulates in the 
thorax with extraordinary rapidity. In an infant ten months old 
the left side of the chest was filled with pus on the sixth day after 



iAm. Jour. Dis. Child., August, 1919. 

2 H. B. Sheffield, "The Backward Baby," p. 72. 

*The cyanosis is caused by an abnormally high oxygen unsaturation of the blood, which mav 
be produced either by an admixture of reduced hemoglobin and oxyhemoglobin in the superficial 
capillaries, or by an incomplete oxidation of the venous blood in the lungs. (W. C. Stadie, 
New York, and C. Lundsgaard, Copenhagen. Jour. Exp. Med., Vol. 30, No. 3.) 



SPECIFIC COMMUNICABLE DISEASES 353 

the onset of the influenza. Otitis is very common during the early 
catarrhal stage of the disease. In the majority of instances the inflam- 
mation clears up without suppuration, but as already mentioned, in 
some epidemics the ear infection is most virulent, sometimes termi- 
nating in mastoiditis simultaneously with the early appearance of con- 
gestion of the tympanum. Nephritis (often hemorhagic) and pyelo- 
cystitis form an early or late complication. In malignant cases the 
peritoneum, pericardium and meninges are attacked in rapid succes- 
sion, in fact, as we are here dealing with a general bacteremia, no 
organ of the body is spared; hence it is of little consequence, from a 
therapeutic point of view, where the infection begins and where it 
ends. Among the milder complications and sequelae we may mention 
cardiac neuroses (bradycardia and tachycardia), neuralgia, neuritis, 
arthritis, adenitis, parotitis, conjunctivitis, inflammation of the acces- 
sory sinuses, and occasionally periostitis. Similar to measles, influenza 
predisposes to tuberculosis, and in a number of instances divers psy- 
choses were noted to follow the disease, sometimes several weeks after 
apparent recovery. 

Finally, every form of cutaneous eruption may accompany influenza. 
At times the eruption is bright red and punctiform, resembling that 
of scarlatina, or roseolar or pustular in character which may readily 
be mistaken for rubeola or varicella. Urticaria is not uncommon, 
and simple erythema may be seen in the majority of cases at some 
stage of the affection. The peculiar facial flush ("lobster face") often 
noted in adults, is very rarely observed in children. The hemorrhages 
in the skin may assume the appearance of purpura hemorrhagica. 

The diagnosis of influenza is comparatively easy during its preva- 
lence in epidemic form, but quite the reverse otherwise. "Colds" and 
gastrointestinal disorders being of such ordinary occurrence in children 
that influenza is generally not thought of when such manifestations 
present themselves. Furthermore, the diagnosis is often obscured by 
the numerous complications. For general guidance in the diagnosis 
we may state that the simultaneous development of respiratory, diges- 
tive and nervous phenomena, leucopenia and marked prostration should 
always arouse our suspicion, even in the absence of an epidemic of in- 
fluenza, i 

As already emphasized the prognosis varies greatly with each epi- 
demic, and the mortality may range anywhere between 10 and 30 per 
cent. Of course, the outcome of the disease depends entirely upon the 
number and severity of the complications. 

Treatment. — Influenza is always to be looked upon as a treacherous 
and dangerous disease, however mild its appearance in its early stages ; 



354 DISEASES OF CHILDREN 

and appreciating the fact that it is so highly communicable and so 
grave in its consequences, it is obvious that every effort must be made 
to arrest the disease at its source by strict isolation of the patient, 
and to employ every means to prevent the grave complications and 
sequelae. During the recent epidemic an attempt was made to attain 
these objects in view by prophylactic vaccination. In order to avoid 
burdensome repetition and controversies of different clinicians, we 
shall take the liberty of citing the views of G-. W. McCoy, 1 Director, 
Hygienic Laboratory, U. S. Public Health Service, which embody the 
consensus of opinion of the profession as a whole. 

Vaccine from Influenza Bacillus as a Prophylactic 

In discussing this subject, we -will give attention, first, to the results obtained 
from the use of a vaccine made from the influenza bacillus alone, or from other 
suspected etiologic agent, which aims, to be sure, to prevent the primary disease, 
and later to a review of the evidence with respect to vaccines which have been 
devised with the special object of preventing the development of pneumonia or of 
mitigating its severity. 

A vaccine made from the influenza bacillus alone seems not to have appealed 
sufficiently to European workers to induce them to try it when the epidemic pre- 
vailed abroad. In this country, its use has been confined largely to New England. 
The early reports on this vaccine were very encouraging; figures were presented 
which, if taken at their face value, would convince any one of the efficiency of the 
agent ; but, when these figures were submitted to careful analysis, much doubt 
remained as to whether the vaccine was of any service whatsoever. The chief source 
of error lay in the fact that the inoculations had been done during the progress of 
the epidemic, and that the case incidence among the vaccinated was compared with 
the case incidence in the general population or in the control groups from the be- 
ginning of the epidemic. Now, it is plain that if, after the epidemic is well under 
way, we vaccinate a portion of the persons in a population, the percentage of per- 
sons attacked will be smaller among the vaccinated than among the nonvaccinated, 
because a percentage of the total number of cases will have occurred before the 
vaccine is given. Not only does this introduce an error by counting in the control, or 
nonvaccinated group, cases that have occurred early, but also it leaves a select 
group to be vaccinated, wholly or in part, in which the percentage of susceptibles 
is smaller than in the original group of which they formed a part. 

To make this clear, let us suppose that ten days after an epidemic started in a 
population of 1,000 persons, an admittedly worthless vaccine was administered to 
one half of those who at that time remained unattacked by the disease. Let us 
further assume that on the date of vaccination 20 per cent of the population 
had sickened, leaving 800 well persons, of whom 400 were vaccinated. Since the 
hypothetical vaccine is worthless, the morbidity will be as great in the vaccinated 
as in the nonvaccinated group. Let us assume this to be an additional 20 per cent. 
Then the total morbidity in the vaccinated group will be 20 per cent of 400, or 
eighty cases. The total morbidity in the unvaccinated, however, if we consider 



ijour. A, M. A, Aug. 9, 1919. 



SPECIFIC COMMUNICABLE DISEASES 355 

the entire period of the epidemic will be 20 per cent of 1,000, or 200, plus 20 per cent 
of 400, or eighty, which would make 280 cases. 

Although the error is now sufficiently clear, we have seen reports which, on the 
basis of the above figures, if applied to this hypothetical worthless vaccine, make 
it appear to be a valuable prophylactic. The statement of these reports would be, 
in effect, that one half of the population was vaccinated, that among the vaccinated 
only eighty cases developed, while among the unvaccinated 280 cases appeared. 
Hence the obvious value of the vaccine. 

We must also remember that a vaccine can scarcely be expected to exert any 
appreciable prophylactic effect before from seven to ten days after the vaccine is 
given, since a week or more is required for immunity to develop. A comparison is 
fair which considers, among both vaccinated and nonvaccinated, only cases that 
have occurred, say, ten days or more after the vaccinations are made. 

When the influenza bacillus vaccine was submitted to such critical tests as the 
inoculation of approximately half of the individuals in institutions, or in other large 
groups, its failure became apparent. A few examples of this are worth citing. 
Hinton and Kane were able to vaccinate about half of the patients at an epileptic 
colony long enough before the disease became prevalent in the institution to justify 
the drawing of conclusions from their data. The vaccine used contained 800,000,- 
000 organisms per mil, and a total of 2,000,000,000 were administered to each per- 
son. The results were as shown in Table 1. 

Table 1. — Effect of Influenza Bacillus Vaccine as a Prophylactic 

not vaccinated 
vaccinated (controls) 

no. per cent no. per cent 

Number of persons 461 .... 518 .... 

Cases of influenza 163 35.4 178 34.3 

Deaths 28 17.0 24 13.5 

On the basis of this experiment the authors reach the obvious conclusion that the 
vaccine was without value. 

A similar test was made on the naval personnel at F'elham Bay Training Station; 
here a part of the individuals of a group were vaccinated, the remainder being held 
as controls. According to the latest available report, 9 per cent of the 554 inocu- 
lated persons developed the disease, and 5 per cent of the 800 who had not been inoc- 
ulated developed it. 

Similar failure attended the attempts at immunization of men at the naval base 
at Paris Island, S. C. It was definitely shown that neither incidence nor severity 
■was influenced by the vaccination. These observations were all on groups large 
enough to make the deductions of value. 

A number of controlled vaccinations, in which influenza bacillus vaccine was 
used, carried out in institutions by the Public Health Service, gave the rather para- 
doxical result of showing an increased percentage of attacks among the vaccinated, 
but more deaths among the nonvaccinated. This result was obtained with a vaccine 
directed against the primary disease, not against the complicating pneumonia. The 
results are shown in Table 2. These figures illustrate the fallacy of giving much 
weight to the results of a small set of observations in work of this sort. 



356 DISEASES OF CHILDREN 

Table 2. — Results Obtained by Influenza Bacillus Vaccine in Institutions 

not vaccinated 

VACCINATED (CONTROLS) 

NO. PER CENT NQ> pER CENT 

Number of persons 484 .... 842 .... 

Cases of influenza 153 31.6 223 26.4 

Deaths 4 1.8 

VACCINES FROM STREPTOCOCCUS AND OTHER ORGANISMS 

Another series of vaccinations aimed directly against the supposed causative 
agent was that reported by Ely, Lloyd, Hitchcock and Nickson. These workers 
believed that the epidemic was due primarily to a hemolytic streptococcus which 
could be detected in the blood and in the lungs. From the fact that the organisms 
with which these observers worked soon lost their chain-forming properties and, in 
some instances, the power to hemolyze promptly, they express some doubt as to 
whether they should be classed as streptococci, and they further assume that there 
are material differences between different strains. The results of the use of a 
vaccine prepared from organisms isolated from the cases were apparently most 
encouraging, though none of the experiments was controlled in a manner that would 
definitely establish the value of the preparation. The work of these observers needs 
to be repeated before the results can be accepted for general application. 

When we come to consider the evidence with respect to the vaccines especially 
designed to prevent the pneumonic complications of influenza, we find again such con- 
flicting reports that one is somewhat bewildered. 

The only papers from a foreign source that have come to my notice are those by 
Eyre and Lowe, who used a mixed vaccine which contained the pneumococcus, the 
streptococcus, the influenza, bacillus, Staphylococcus aureus, Micrococcus catarrlialis, 
B. pneumoniae and B. septus. 

These authors believe, and indeed present rather convincing figures in their first 
paper to prove their point, that the use of this vaccine produces lowered resistance, 
which may last for ' ' from a few hours to two or three weeks, ' ' during which period 
the incidence of respiratory infections would be increased among inoculated groups. 

The early experience of the English authors does not refer directly to the pro- 
phylaxis of influenza, but it is cited here to show that there may be an element of 
danger in the indiscriminate use of vaccines in the presence of a rapidly spreading 
epidemic like influenza in which naturally many persons in the *' negative phase" 
would be attacked. 

In a later paper, the same writers report on the experience with vaccine in the 
epidemic in England in the autumn of 1918. Stress is laid on the necessity of 
preparing a vaccine from cultures but recently isolated. 

The figures given and the facts presented by these writers are difficult of inter- 
pretation and permit of almost any conclusion that one wishes to draw from them, 
from the optimistic one that fatalities after influenza occur only among the non- 
vaccinated, to the pessimistic one that fatalities occur only among the vaccinated, 
though the authors believe the results were good. They frankly reiterate the opin- 
ion that for a short time following vaccination there is an increased incidence among 
the vaccinated, owing to temporarily increased susceptibility, but the writers con- 
sider that this risk is justified by the benefit that they believe may accrue later. As 
inoculations were performed largely during the prevalence of the epidemic, and as 



SPECIFIC COMMUNICABLE DISEASES 357 

the controls appear to include persons who developed the disease prior to the vac- 
cination, the alleged good results may be misleading. 

THE POLYVALENT VACCINE OF EOSENOW 

Kosenow prepared a mixed, and, at least in part, polyvalent, vaccine from the 
various fixed types of pneumococci, pneumococci of Group IV, hemolytic streptococci, 
Staphylococcus aureus and the influenza bacillus, all of which had been recently 
isolated. This vaccine was adjusted to meet the bacterial flora encountered during 
the epidemic ; thus, in a manner it may be said that it was designed to approach an 
autogenous vaccine, but was intended primarily for prophylactic purposes. Dr. 
Kosenow felt that this vaccine should be prepared for use in any community from 
the strains of organisms there prevailing, and that a vaccine adjusted to meet the 
needs of one locality might not meet those of another. The figures given for pro- 
tection are encouraging, but do not lend themselves to critical analysis. 

Vaccine prepared in the manner suggested by Dr. Kosenow should theoretically 
have a better chance for success than those we shall next consider, but the practical 
difficulties of preparing it from locally prevailing strains and adjusting it to meet 
the changing flora of the respiratory tract in a disease that spreads as rapidly as 
influenza are obvious. 

A specimen of the vaccine which was being used in Illinois was tried in Cali- 
fornia, under rigidly controlled conditions, without success. The disease did not 
appear in the institution where the test was made until eleven days after the last 
injection, but, after the epidemic had swept through it, the results revealed that 
37 per cent of the vaccinated were attacked, against 28 per cent of the controls, 
while 4.5 per cent of the vaccinated population died, against 3.6 per cent of the 
nonvaccinated. These are differences too small to be significant. Tests made in 
other institutions gave similar results, though we need not take the time to con- 
sider the details here. 

The only report we have on a vaccine directed against the influenzal pneumonias 
associated with the fixed types of the pneumococcus is that of Cecil and Vaughan, 
whose work was conducted at Camp Wheeler and was directed primarily against the 
usual pneumonias of the camp. Apparently the antipneumococcus vaccine reduced 
somewhat the incidence of influenzal pneumonia among the vaccinated, though, to 
use the author 's words, ' ' influenza causes a marked reduction in resistance to 
pneumonia even among vaccinated men." These authors show clearly that the case 
mortality of secondary pneumonias was not reduced by the vaccination, contrary 
to the claim so often made, that the vaccine, when it fails to protect perfectly, at 
least leads to a milder type of the disease. Cecil and Vaughan believe that the 
results of their experiment with respect to pneumococcus pneumonia were obscured 
by the influenza epidemic; evidence that the prophylactic action of the vaccine 
employed against influenza was not striking, since the epidemic should have served 
to emphasize rather than obscure the results of the beneficial action of a really 
valuable prophylactic agent. 

The general consensus of opinion of the profession seems inclined 
to the belief that prophylactic and therapeutic vaccination has failed 
in a definite manner to influence either the morbidity or the mortality 
of influenza. 

Until a specific vaccine or drug against influenza will be perfected, 
we will be obliged to treat it symptomatically : the salicylates, with 



DISEASES OF CHILDREN 



or without quinine and phenacetin, for the relief of temperature and 
pain; mild expectorants, with or without small doses of codeine, to 
allay the cough; heart tonics, especially digitalis, to sustain the heart's 
action; hydrotherapy in the form of cool sponging or warm baths for 
hyperpyrexia; oxygen for the dyspnea and cyanosis; lumbar puncture 
for delirium and convulsions, and absolute rest in bed and a light diet, to 
maintain the patient's vitality. The nose, mouth and throat should be 
kept clean by means of Dobell's solution, and the alimentary tract free 
from putrefactive matter by a daily intestinal irrigation and mild 
laxatives. Complications arising should be treated according to in- 
dications. (See "Pneumonia," "Nephritis," "Peritonitis," "Enceph- 
alitis," etc.) 



R Acid. Acet. Salicyl. gr. xv 


1.00 


Caff einag Natrii Benz. gr. v 


0.3 


Chocolate et Sacehari q. s. 




M. 




Div. in pulv. No. viii. 




S. — One powder every three hours, for a 


child 


three years old. 




IJ Natrii Salicyl. 3 ss 


2.0 


Potassii Citratis 3 i 


4.0 


Extr. Glycyrrhizae Fl. 3 ii 


8.0 


Aq. Anisi q. s. ad f § ii 


60.0 


M. 




S. — One teaspoonful every three hours, 


for a 


child three years old. 




B Liq. Anmionii Anis. 3 ss 


2.0 


Natrii Benzoici 3 ss 


2.0 


Syr. Ipecacuanhae 3 i 


4.0 


Tr. Digitalis 3 ss 


2.0 


Syr. Althese E i 


30.0 


Aq. Anisi q. s. ad f § ii 


60.0 


M. 




S. — One teaspoonful every four hours, 


for a 


child three years old. One-twentieth of a 


grain 


of codeine may be added to each dose o 


f the 


above medicine, if the cough is distressing 


r 
j" 


Rubeola 




(Morbilli, Measles) 





Measles is probably the most frequent and most readily communicable 
eruptive fever of childhood. Children of from two to six years are 
most susceptible to it, but it is not rarely met with in older and younger 
ones, and cases in the newborn have been reported. In the majority of 



SPECIFIC COMMUNICABLE DISEASES 



359 



instances one attack immunizes the patient against another one, numer- 
ous exceptions, however, are on record. The cases of recurrent measles 
often prove to be rubeola on one occasion, and rubella, or a similar skin 
eruption, en another. The disease is communicable in all its stages 
(particularly the catarrhal stage) by means of the as yet unknown con- 
tagium* — which dwells in the lacrimal, nasal, and bronchial secretions, 
and probably also in the papules and squamae — either by direct contact 
or, more rarely, through intermediate persons, the air, or fomites. 
Nine to fifteen days — the period of incubation — pass after invasion of 
the system by the materia morbi without any characteristic manifesta- 
tion of ill health, except slight anorexia, restlessness, ephemeral rise 
of temperature, etc., which toward the end lead to a more acute aggra- 
vation of the condition and mark the beginning of the prodromic stage. 



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Fig. 86. — Fever curve of measles. 

This stage usually lasts three days, rarely longer (up to a week in de- 
bilitated children). The little patient complains of chilliness, headache, 
and fatigue, hangs its head or sleeps most of the time, coughs and occa- 
sionally sneezes, and presents a rise of temperature of from 2° to 4° F. 
Not rarely the fever drops the next day, but the catarrhal symptoms 
continue in severer form. Examination of the mouth and throat in the 
majority of cases reveals upon the mucous membranes of the soft and 
hard palate diffuse redness or punctiform or stellate spots, and on the 
buccal mucous membrane and inner surface of the lips from six to 
twenty, rarely more, red spots, with a central, rounded, slightly elevated 
bluish efflorescence. These spots never cause pain or ulcerate. They 
are called Koplik spots — the latter deserving the credit of having proved 



*R. Tunnicliff (Jour. A. M. A., April 7, 1917) has discovered a coccus in the blood and in 
the nose and throat in the verv early stages of measles. Whether this coccus is the primary 
cause or a secondary invader is still undetermined. Measles has recently been produced ex- 
perimentally. 



3G0 DISEASES OF CHILDREN 

the pathognomonic significance of the spots as an early sign of measles. 
This enanthema of the buccal mucous membrane not rarely appears 
from three to five days before the exanthema. 

Another twenty-four hours and the eruptive stage is reached. Bright 
red, pinhead- to lentil-sized dots appear over the forehead, about the 
ears and over the face (chin and around the nose and mouth — circum- 
oral ring), and rapidly enlarge to irregularly serrated, pea- and bean- 
sized, sharply circumscribed, rounded or crescentic, slightly elevated 
red spots, which disappear on pressure. From these points the erup- 
tion rapidly spreads, often in crops, over the body and limbs, taking 
about twenty-four hours to complete the process. At this time the 
catarrhal symptoms also are at their height. The face is flushed and 
edematous, the eyes are red and watering and dread light; the nasal 
catarrh is intense, the cough frequent, harsh and often barking, the 
voice hoarse, the temperature high (104° F., or higher), the urine 
scanty and high colored (diazo reaction often positive) ; the child is 
drowsy, at times delirious, often vomits and occasionally suffers from 
diarrhea (sometimes bloody, especially during the hot summer months). 
The peripheral and lymphatic glands are not rarely swollen and pain- 
ful, and the spleen is somewhat enlarged. 

It is generally accepted that cases of measles in which the exanthema 
appears on the back first are usually grave in character. The same 
holds true of the cases in which the exanthema suddenly fades. 

The eruptive stage lasts from five to six days. Toward- the end 
of the stage the eruption begins to fade, especially on the face, and 
bran-like scales take the place of the exanthema. With the fading 
of the eruption there is often a critical decline of the temperature 
(sometimes preceded by morning or evening remissions) and its con- 
comitant symptoms, except the bronchial catarrh. The desquamative 
stage lasts about one week, so that the patient is usually entirely well 
by the end of the fourth week from the time of infection. Sometimes 
traces of the exanthema in the form of bluish-red spots remain over 
some portions of or the whole body which do not disappear on pres- 
sure with the finger. They are of no special significance. 

Deviations from the typical course of the disease are not rare. Thus, 
the exanthema may be absent or so scanty as to escape observation — 
morbilli sine exanthema — notwithstanding the pronounced character of 
the catarrhal and febrile symptoms. In such cases the diagnosis from 
the grip is almost next to impossible, and can at best only be surmised in 
the presence of an epidemic or another case of measles in the immediate 
surroundings. 

The eruption may appear in the form of small papules, at times pene- 




PLATE VI 



Buccal Exanthema in Measles (Koplik's Spots) 

(Courtesy of Dr. John Zalwrsky.) 



SPECIFIC COMMUNICABLE DISEASES 361 

trated by a hair — morbilli papulosi; or be covered by minute vesicles — 
morbilli miliar es. 

The appearance of the exanthema may be delayed for a clay or two 
and then be localized principally upon the body and limbs or become 
confluent so as to resemble the rash of scarlatina — morbilli scarlatinosi. 
Occasionally small hemorrhages occur between the spots — morbilli hemor- 
rliagici. This form of measles is not to be mistaken for morbilli hemor- 
rhagic! malign% "black measles," which is rather very rare and observed 
only in delicate, cachectic children. In this condition instead of the 
eruption there are numerous petechia? and ecchymoses, in addition to 
hemorrhages from the nose, ears, genitalia, kidneys or bowels. Malig- 
nant measles is usually associated with early depression, very high 
temperature, rapid and frequent pulse, dry, brown and thickly coated 
tongue, sopor, convulsions and coma, and often ends fatally within 
three days. 

Occasionally the temperature is protracted or after a fall suddenly 
rises, indicating the occurrence or near advent of complications or 
sequelae. Ordinarily complications set in toward the end of the erup- 
tive stage, but may appear as early as the prodromic stage. At this 
period also we are apt to find angina tonsillaris, epistaxis, severe vomit- 
ing and diarrhea, catarrhal laryngitis, pneumonia, etc. 

In the eruptive stage pneumonia forms the chief complication. Vio- 
lent coughing is prone to give rise to laceration of the lungs and con- 
secutive ''pneumohypodernia." (See p. 344.) Quite frequently we 
meet also with pseudocroup and more rarely with diphtheria. The 
diphtheria of the throat sometimes develops secondarily to that of the 
conjunctiva; more frequently, however, the former occurs primarily, 
and the diphtheritic conjunctivitis remains limited to the original 
focus. It was my privilege to see 2 cases in point. One boy, six years 
old, succumbed to laryngeal diphtheria complicating measles, while his 
brother, three years old, was saved from blindness, and perhaps death, 
by early administration of antitoxin. The affected eye presented a 
clinical picture resembling that of gonorrheal ophthalmia. The diph- 
theritic conjunctivitis cleared up entirely withn ten days, but was 
followed by typcal diphtheritic paralysis of the throat. Severe stoma- 
titis is not uncommon, and numerous cases of noma (q.v.) complicat- 
ing or following measles are on record. The same observation holds good 
for divers forms of ear affections. Measles is not infrequently asso- 
ciated with typhoid, erysipelas, varicella, scarlatina, and acute pemphi- 
gus. The latter eruption may become gangrenous and prove fatal. 
The tendency to gangrene of apparently mild lesions of the mucous 
membranes and skin should always be borne in mind, as it is not at 



3G2 DISEASES OF CHILDREN 

all rare to find general sepsis supervening just such lesions. Measles 
acts as a great predisposing cause to pertussis, which latter may prove 
very serious owing to early supervention of bronchopneumonia. Sudden 
heart paralysis is rare. 

Among the sequelae the following affections deserve special empha- 
sis: otitis, chronic conjunctivitis, keratitis, deafness, deafmutism, os- 
teomyelitis, purulent pleurisy or pericarditis, nephritis, chronic bron- 
chopneumonia, psychoses, meningitides and other nerve affections. 

Measles manifests also a great disposition towards pulmonary tubercu- 
losis (from 5 to 15 per cent of cases in some epidemics). As distin- 
guished from scarlatina the blood in measles shows a subnormal num- 
ber of leucocytes or a leucopenia. 

Fortunately, most of the aforementioned complications and sequelae 
are rare. Ordinarily, measles runs a benign course. Still, measles 
should always be looked upon as a very serious disease, especially if 
it attacks very young and delicate children and those with a tainted 
hereditary disposition. Indeed, in such children, especially if housed 
in asylums or hospitals, the mortality may vary from 20 to 40 per 
cent. 

Treatment. — The custom still prevailing with some ignorant people 
to congregate the children free from measles with those affected by it, 
so that "they should all have it at once" is condemnable. Isolation 
of the patient should be insisted upon, and all other precautions avail- 
able strictly adhered to. (See p. 69.) 

The use of convalescent serum as a preventive and curative of 
measles has lately engaged the attention of pediatrists. The results 
are still sub judice. The usual measures in the treatment of measles 
consist principally of active diaphoresis by hot drinks, hot baths, and 
diaphoretics (decoction of crocus one dram to % pint), and minute 
doses of an opiate and expectorants to relieve and loosen the cough. 
Attention to complications is all important, whether grave or mild. A 
light diet should be enforced as long as the temperature is above 
normal. The fear of free ventilation of the sick-room is unfounded. 
On the contrary, a liberal supply of fresh air (68° to 70° F.) should 
be allowed as a therapeutic measure. Where photophobia exists, the 
room should be darkened by shades. 

The mouth and eyes should be kept clean with warm boracic acid 
solutions, and the nasopharynx by instillations of a few drops of al- 
bolene. The temperature and nerve irritability should be reduced by 
small doses of phenacetin (y 2 grain for every year of the child's ago) 
as well as by warm baths or packs (90° F.). 

Other symptoms should be treated according to indications. 



SPECIFIC COMMUNICABLE DISEASES 



363 



Iy Liq. Ammonii Aiiisat. 3 ss 2.0 

Potassii Citratis 

Syr. Ipecacuanha aa 3 i 4.0 

Syr. Picis 3 iv 15.0 

Aq. Anisi q. s. f § ii 60.0 

M. 
S. — One teaspoonful every three hours, for a 
child four years old (useful diuretic, diaphoretic 
and expectorant). A small dose of codeine or 
heroin may be added, if the cough interferes 
with the child's rest. 

For differential diagnosis see p. 398. 

Rubella 

(Rotheln, German Measles, Epidemic Roseola) 

On superficial examination rotheln closely resembles measles, but 
on careful observation it is found to differ from it in so many respects 
as to justify its classification into a distinct disease. It is highly 
communicable and often occurs in epidemics. One attack confers but 



DAY 1 2 3 4- 5 6 7 8 9 10 11 12 13 14 15 


TIME MEMEMEMEMEMEMEMEMEMeMEMEMEMtMle 








103 










102° 




- 1 4 






101 jt t I -* 


. , ,tl \>T 


U r-V ' 


J-h-t - 


I 




. .1 V 


tt i r. 


t i. 


o L 




. .? T 


4 J 


t t k- 


o 1 x-i« — 







Fig. 87. — Fever curve of German measles. 

little immunity against another, and not at all against genuine measles. 
The incubation period lasts from ten to twenty-one days, and is gen- 
erally free from any manifestations. There are none or very slight 
prodromata of from twenty-four to forty-eight hours' duration, con- 
sisting of languor, anorexia, and slight catarrhal symptoms, such as 
mild injection of the conjunctiva, short cough and slight rhinitis. The 
eruption usually appears suddenly, first on the face, and within from 
twelve to twenty-four hours over the entire body. Often it has dis- 



364 DISEASES OF CHILDREN 

appeared from the face by the time the extremities are involved. The 
rash appears in tivo forms. One resembles that of measles — pale, red 
papules, up to the size of a lentil, usually discrete, rarely confluent, and 
momentarily disappearing on pressure. The other form is finely punc- 
tate, and coalesces into diffuse rose-red patches — resembling the rash 
of scarlatina. The eruptive stage lasts from three to four days, and 
is usually free from severe general symptoms. It is occasionally fol- 
lowed by slight desquamation of the upper part of the thorax and 
thighs. During the height of the exanthema, there may be a rise of 
temperature, of two or three degrees, but it is only of short duration. 
As in measles, the mucous membrane of the throat is the seat of dif- 
fuse or dotted redness or yellowish miliary vesicles; the buccal mu- 
cous membrane, however, shows no Koplik spots. Most patients com- 
plain of sore throat during the acme of the disease, but not nearly as 
much as in scarlatina. The superficial glands, particularly the suboc- 
cipitals and those in the region of the angle of the jaw, the submax- 
illary, and less frequently those of the axilla, groin, etc., are enlarged 
and tender. In severe cases there is usually also moderate enlargement 
of the spleen. 

The differential diagnosis between rubella and rubeola will be outlined 
on page 398. Attention will here be directed, however, to the frequent, 
nay, almost constant, occurrence of free perspiration in rotheln, a 
symptom, almost never met with in genuine measles. "Where Jthe rash 
is scarlatiniform, it may in the beginning be confounded with scarlet 
fever, but in the latter affection there are marked initial symptoms 
(vomiting!), high fever and pulse, and more severe throat manifesta- 
tions. 

Numerous so-called heat and stomach rashes greatly resemble Ger- 
man measles, and it is not always easy to tell them apart, particularly 
in the absence of an epidemic of rotheln. Under the circumstances 
it is safer to reserve the diagnosis for about twenty-four hours, and 
watch the results of a "cooling lotion" and a laxative. 

For its differentiation from Dukes' disease, see p. 398. 

Rubella is considered the mildest of all acute exanthematous in- 
fectious diseases, and, as a rule, terminates favorably within one week 
from the onset of the symptoms. But in view of the occasional occur- 
rence of serious complications (severe angina, bronchopneumonia, sup- 
purative adenitis, and even meningitis), it should always receive proper 
attention, especially in the way of rest in bed, light diet, cleansing 
of the nasopharynx, and good hygiene. (See also Treatment of mea- 
sles p. 362.) 



SPECIFIC COMMUNICABLE DISEASES 365 

Diphtheria 

Diphtheria is caused by a bacillus discovered by Klebs and Loffler 
in 1883. The bacillus is found in the secretions and excretions of the 
structures involved, and is transmitted usually through direct personal 
communication (kissing, sputum, etc.), but probably also through the 
agency of dishes, clothing, milk, etc., and through a third person, the 
so-called diphtheria carrier. The bacillus is very tenacious to life. 
It is said to remain in the throat of convalescents for several months 
or longer, and rooms previously occupied by diphtheria patients and 
left vacant for weeks frequently harbor infective diphtheria bacilli, 
having resisted disinfection and prolonged ventilation. 

The diphtheria bacilli have a predilection for the lining of the naso- 
pharynx and larynx, especially of children from two to eight years 
of age. It is less common in infants under a year and very exceptional 
in the newborn.* Far more seldom they attack other parts of the body, 
e. g., intestines, the eyes, the mouth, and the vulva. After imbedding 
themselves into the primarily affected structures, the bacilli multi- 
ply and secrete their toxins (albuminoses and organic acids), which 
enter the tissues and lymphatics and thence produce general infection. 
The diphtheria bacillus is often associated with strepto- and staphylo- 
cocci and other bacteria. 

Morbid Anatomy. — Diphtheria is characteristic for its formation of 
a fibrinous exudation produced by the entrance of the Klebs-Loffler's 
bacillus and other microorganisms into the superficial tissue layers. 
It is primarily a superficial destructive process which always ends in 
ulceration by separation of the tissues in the form of a true membrane. 
It differs from a croupous process only in the degree of severity of the 
inflammation. Gangrenous processes are sometimes associated with 
diphtheria, extensive putrid decompositions developing beneath the 
diphtheritic infiltration or upon the base of the diphtheritic ulcer. In 
healing, the entire necrotic process must first slough off, and the epi- 
thelium be replaced by scar tissue. 

In all cases the neighboring lymphatic glands are swollen, hyper- 
emic, intensely edematous and sometimes phlegmonous; and in severe 



*Becker states that at the Jena maternity there were five cases of nasal diphtheria in new- 
born infants in 1918 and four in 1919. He warns that bacteriologic examination is indispensable 
for every case of coryza in a young infant and above all when the discharge from the nose 
shows traces of blood. In one case the nasal diphtheria entailed general sepsis with mixed in- 
fection and necrosis of the arm. The snoring breathing is the first symptom to attract attention, 
and then the thin, slightly purulent discharge running from one or both nostrils. It is often 
reddish or brownish, and erodes the upper lip. The membranes are generally far back in the 
nose, but can be easily removed. Becker ascribes the infection to carrier visitors as the most 
probable source. On this account it is now the rule not to give the child to its mother to 
nurse during "visiting hours," and no outsider is allowed in the infants' ward. In a recent 
compilation of thirty -eight cases the mortality was 31.6 per cent, mostly from complications. 
In another case the diphtheria settled in the cord. 



dbb DISEASES OF CHILDREN 

cases there is usually an extension of the diphtheritic process from the 
pharynx to the nose, larynx, trachea and bronchi. Owing to its thick 
and dense epithelial covering the esophagus is very seldom involved. 
If the lungs become affected, the lesions usually consist of small lo- 
bular pneumonic foci, especially in the posterior lower portion of the 
lungs. Degenerative changes in the heart, spleen, liver, kidneys, in- 
testines and cerebrospinal system are not uncommon evidences of the 
diphtheria toxin. The blood shows no definite changes. 

Symptomatology. — The incubation period varies from two to ten days. 
As a rule, the onset is sudden with vomiting, headache, chills, fever, sore 
throat, and difficulty in swallowing. Not rarely however it is preceded by 
indefinite signs of ill health of a few days' duration, consisting of ano- 
rexia, lassitude, slight fever, irritation of the respiratory tract, etc. In 
such cases the active stage of the disease may insidiously follow upon the 
prodromic stage without any pronounced variation in the clinical mani- 
festations, the throat symptoms often remaining latent until discovered 
by a routine examination or unmasked by grave correlative symptoms. 
This is especially apt to occur in infants. The importance of a routine 
examination of the throat of children in all kinds of complaints, there- 
fore, is obvious. 

The initial symptoms of the disease are not very characteristic, 
especially if the attack is mild. The uvula and tonsils are inflamed 
and somewhat enlarged. Careful inspection of the throat usually re- 
veals upon the inner tonsillar or faucial surfaces a small, uneven, 
grayish-white, slightly elevated patch, or a few gray streaks or hem- 
orrhagic specks. Within a few hours the deposit is found to have 
spread over both tonsils or also to the palatine arches and the posterior 
pharyngeal wall, giving the appearance of a greenish-white, sharply 
defined, firmly adherent membrane, which, if forcibly detached, leaves 
a raw, bleeding surface, and reforms very soon after. As the deposit 
assumes greater dimensions, the cervical and submaxillary glands, 
which at first are but slightly involved, become large and hard, assume 
the shape of large walnuts, and are very painful to the touch. De- 
glutition is difficult but not very painful — due to partial degeneration 
of the pharyngeal muscles and their nerves. The aforementioned con- 
stitutional symptoms continue. 

The symptomatology thus far represents the first stage of a mod- 
erately severe attack of pharyngeal diphtheria. From now on three 
eventualities are possible: (1) The clinical picture may remain sta- 
tionary; (2) the disease may spread to the nose from the pharynx; (3) 
the diphtheritic process may extend dowmvard to the larynx. 




PLATE VII 



Tonsillar Diphtheria 

(Courtesy of Dr. John Zahorsky.) 



SPECIFIC COMMUNICABLE DISEASES 367 

Since the introduction of antitoxin treatment of diphtheria the number 
of cases falling into the first category has enormously increased. "With 
early treatment the disease is rapidly arrested, the membranes are cast 
off spontaneously, and the patient makes an uneventful recovery with- 
in from four to eight days. Less frequently the second or third pos- 
sibility occurs. Either as a result of extreme virulence of the in- 
fection or of negligence or improper treatment, the nose or larynx 
or both becomes invaded. In nasal diphtheria (rhinitis fibrinosa et 
mernbranacea) , in addition to the previously mentioned symptoms, nasal 
breathing is obstructed greatly. The child keeps the mouth widely 
open, snores, is very restless, speaks through the nose, is almost 
unable to swallow, has fetor ex ore, and coryza with seropurulent or 
hemorrhagic discharge. In laryngeal involvement (diphtheritic croup). 
symptoms of laryngeal stenosis predominate. The child's voice becomes 
husky, then hoarse, aphonic, and its breathing noisy, rough and wheez- 
ing, and as the disease advances, it is attacked by a barking, croupy 
cough, dyspnea, retraction of the lower portion of the sternum and the 
ribs with each inspiration, and cyanosis. The dyspnea often occurs in 
paroxysms, which greatly resemble those of spasmodic croup (q.v.), 
and grow worse from time to time. Unless the air passages are promptly 
freed from the obstruction by intubation (q. v.) or tracheotomy (q. v.), 
the patient passes into a state of stupor and finally succumbs to the 
effects of increase of carbonic acid and deficiency of oxygen in the lungs. 

Both laryngeal and nasal diphtheria may develop primarily, and 
later become associated with pharyngeal diphtheria. 

The course of the disease varies greatly with the location of the lesion, 
severity of the attack, and the period at which treatment is begun. 
Pharyngeal diphtheria usually pursues the most favorable course. Mild 
cases, as mentioned, may end in complete recovery in from four to eight 
days. In severer cases, the symptoms niay increase in intensity up to 
the fifth or sixth day, and then begin to abate, and after a rapid or 
protracted course finally subside. The same holds true of nasal or laryn- 
geal diphtheria, provided treatment is instituted early and no complica- 
tions supervene. Unfortunately in the latter form of the disease com- 
plications are of quite frequent occurrence. Exhausted from the pros- 
trating effects of the paroxysmal attacks of laryngeal stenosis, the child 
is unable to withstand the onslaught of the diphtheritic poison (some- 
times also mixed diphtheritic and streptococcic infections). The de- 
posit, originally limited to the upper portions of the larynx, rapidly 
extends downward, involving the trachea and bronchi — leading to croup- 
ous bronchitis and pneumonia, and, as a rule, to a fatal issue —and up- 
ward, exerting its destructive action upon the pharyngeal, oral and nasal 



3G8 DISEASES OF CHILDREN 

structures, often resulting in perforation of the palate, gangrenous 
sloughing of the uvula, etc. These cases of so-called diphtheria gravis- 
sima s. maligna sometimes develop very slowly and insidiously (diph- 
theria larvata) with symptoms of slight indisposition, slight rise of tem- 
perature, bronchial or gastrointestinal catarrh, and after a period of 
from a week to ten days are abruptly announced by true croup and the 
accompanying grave manifestations. Occasionally this form of the dis- 
ease pursues a septic course right from the start, irrespective of the 
location and extent of the deposit. The virulent process is supposed 
to be due not only to the diphtheria toxin, but to the immediate entrance 
of the bacillus itself into the circulation. It is characterized by vomiting, 
prostration, puffiness and earthy pallor of the face ; small, often irregu- 
lar pulse ; epistaxis ; bleeding from the mouth, pharynx or into the skin. 
The urine is scanty, loaded with albumin; the temperature may be 
slightly raised or below normal. Within from three to five days the 
child dies, in a state of low muttering delirium, from gradual exhaustion, 
or earlier from cardiac paralysis. On postmorten examination, in addi- 
tion to the diphtheritic lesions pathognomonic of all forms of the disease, 
the spleen is found enlarged, the kidneys, liver, and heart in a state of 
cloudy swelling — a group of pathologic findings ordinarily met with in 
severe infectious diseases — and, varying with the intensity and number 
of complications, divers lesions in other organs of the body (e. g., lungs, 
brain and alimentary canal). 

There is nothing definite about the number and severity of the com- 
plications in any given case. As already stated, mild cases may become 
severe and exhibit all sorts of complications and sequelae and vice versa, 
cases with severe onset may under proper treatment remain free from 
either and end favorably in a comparatively short space of time. Kid- 
ney, heart, lungs and nerve diseases form the most frequent complica- 
tions and sequelae and in the majority of instances are the result of mixed 
infection. Transient albuminuria is often observed even in mild cases. 
It usually begins on the third or fourth day of the disease, sometimes 
earlier or later, and disappears with abatement of the other diphtheritic 
symptoms. Occasionally we find true nephritis diphtheritica, with large 
quantities of albumin and casts and more rarely also blood. The neph- 
ritis may also set in as a late sequel, during apparent convalescence, 
and remain more or less permanent. As a rule, however, the nephritis 
is of short duration, and rarely gives rise to local or general dropsy. 
By far more serious is the accompanying heart affection — so-called 
''heart paralysis" from involvement of the pneumogastric nerve. It is 
often manifested by sudden heart failure, and may set in either during 
the acme of the disease or any other time between then and as late as 



SPECIFIC COMMUNICABLE DISEASES 369 

from four to six weeks after ; sometimes while the patient seems in very 
good health. It is apt to arise on the slightest exertion. The heart paral- 
ysis is not invariably sudden and fatal, however. Quite often it is pre- 
ceded by heart weakness with symptoms of dilatation — interstitial myo- 
cardial degeneration — such as extreme pallor, feeble, rapid and irregu- 
lar pulse, attacks of syncope, albuminuria, exhausting diarrhea, some- 
times apathy, somnolence, sopor and death; or, less frequently, very 
slow convalescence, and gradual recovery, usually with remaining heart 
disease. Occasionally diphtheria is complicated by pericarditis or endo- 
carditis. Bronchitis and pneumonia are especially prone to occur in 
laryngeal diphtheria, as a result of direct extension of the diphtheritic 
process to the trachea, bronchi, etc. (in intubated cases through the 
entrance of foreign bodies, particles of food, etc., into the air passages — 
"aspiration pneumonia") but also in other forms of the disease. The oc- 
currence of pneumonia greatly mars the prognosis. 

The most frequent sequel — occasionally also complication — of diph- 
theria is multiple neuritis, "diphtheritic paralysis," It is due to 
an intense degeneration of the peripheral nerves up to their roots. It 
follows in about one-tenth of all cases, probably mild and severe alike. 
It generally develops about the third or fourth week after the onset 
of diphtheria, sometimes earlier or later, and affects the muscles of 
the soft palate by preference, causing a nasal tone of voice, and re- 
gurgitation of fluids through the nose. In combined esophageal and 
laryngeal paralysis there is also great difficulty in deglutition, not 
rarely giving rise to "aspiration pneumonia," as a result of entrance 
of part of the food into the air passages. These disturbances usually 
disappear spontaneously or on suitable treatment, within from four 
to six weeks. The paralysis may extend to the eye muscles and cause 
strabismus, oculomotor, paralysis, disturbance of accommodation and 
even total ophthalmoplegia. Less frequently the muscles of the trunk 
and extremities are implicated. (See Fig. 196.) The symptoms resulting 
are more or less identical with those observed in cases of multiple neur- 
itis from other causes, and vary in intensity from simple motor weakness 
and ataxic gait to hemiplegia. In severe cases the tendon reflexes and 
faradic irritability are entirely lost, and the muscles undergo atrophy. 
Nevertheless, recovery is the rule in the majority of cases, except when 
complicated by paralysis of the respiratory muscles (diaphragm) and 
the aforementioned baleful sudden heart failure. As regards the hemi- 
plegia, it is still uncertain, whether it is a genuine diphtheritic paral- 
ysis or caused by underlying alteration in the brain, such as cerebral 
hemorrhage, or cardiac thrombosis with embolism of the arteria fossas 
Sylvii, since the hemiplegia not rarely begins with convulsions, loss 



370 



DISEASES OF CHILDREN 



of consciousness, and is often associated with aphasia and facial paral- 
ysis. If the patient survives the attack, the hemiplegia symptoms usu- 
ally subside within a few weeks, but weakness and contractures of the 
extremities may remain permanent. 

Less common complications and sequela? are arthritides, otitis, pleu- 
ritis, peritonitis, suppurative adenitis, diphtheritic affections of the 
stomach, diphtheritic ophthalmia, various rashes, etc. 

From the foregoing discussion it can readily be appreciated that 
a positive prognosis is almost impossible. It should always be guarded, 
no matter how mild the case. The gravity of the epidemic, the sever- 




With Each Day's Delay in Giving Anti- 
toxin, See How the Danger Increases! 

Chart I 



ity of the attack, the strength and age of the patient, the quality of 
the heart, the period at which antitoxin has been administered — all 
have an important bearing upon the outcome of the case. However, 
no case should be despaired of, no matter how grave. Antitoxin treat- 
ment often performs miracles, even in apparently hopeless cases. 

Treatment. — With the advent of the serum treatment, diphtheria 
has ceased to be the dread of the community. The mortality of diph- 
theria which previously ranged between 50 and 75 per cent, has now 
dropped to about 5 per cent in pharyngeal and to 20 per cent in laryn- 
geal diphtheria — the earlier the serum treatment is begun with the 



SPECIFIC COMMUNICABLE DISEASES 371 

lower the mortality. Indeed, by administering diphtheria antitoxin 
at the very inception of the disease we are often enabled to limit the 
latter to its local manifestations — almost free from constitutional symp- 
toms. Furthermore, those coming in close contact with the diphtheria 
patient may by means of from 500 to 1,000 units of antitoxin be im- 
munized against this affection for a period of from four to six weeks. 

In a great many instances, especially in children's hospitals and asy- 
lums where large numbers of children are congregated, immunization 
may in many cases be dispensed with by employing Schick's toxin skin 
reaction (see p. 74), since it enables us to determine the susceptibility 
to or immunity against diphtheria. Moreover, as already emphasized on 
pp. 75, 76 permanent immunity may be effected by means of diphthe- 
ria toxin-antitoxin. 

Immunization and isolation of the patient are the most potent prophy- 
lactic measures of diphtheria. As the nasopharynx forms the prin- 
cipal nidus for the development and spread of the diphtheria bacilli 
and their toxins, cleansing of the nasopharynx by means of mild 
antiseptics (instillation of Dobell's solution three or more times a 
day) will often aid in the prevention of infection. This prophylactic 
measure should be employed in conjunction with immunization by 
antitoxin, or without the latter, wherever there are contraindications 
to its use (e.g., status lymphaticus, hemophilia) or objections on the 
part of the family. Heart disturbances being the most dangerous com- 
plication of diphtheria, the heart should receive very careful attention, 
even in the mildest form of the affection. It should be examined daily, 
especially as regards acute dilatation of the heart. The patient should 
be kept under observation for at least three weeks after abatement of 
the acute course of the disease, and in the event of any untoward symp- 
toms arising, immediately be put to bed and treated in accordance with 
the directions presently to be outlined. Even with an apparently nor- 
mal heart it is imperative to keep the child perfectly at rest in bed 
for at least ten days after disappearance of the local symptoms. As to 
the prevention of "aspiration pneumonia," the reader is referred to the 
chapter on "Intubation." 

The active treatment of diphtheria can be summarized in a few words : 
counteract the diphtheria toxin ; arrest the local lesion ; and increase 
the power of resistance of the patient. When called upon to see a case 
of sore throat or laryngitis that is strongly suspicious of being diph- 
theritic in nature, we should immediately administer diphtheria anti- 
toxin and lose no time in waiting for the results of a bacteriologic exami- 
nation. The serum should be administered by deep hypodermic in- 
jections, a syringe somewhat larger than the ordinary hypodermic syr- 



372 DISEASES OF CHILDREN 

inge being preferably employed for this purpose. The lateral surface of 
the abdomen or thorax or the outer surface of the thigh, where there is 
an abundance of subcutaneous cellular tissue, is generally chosen for 
the injections. Previous to the administration of the antitoxin the 
skin should be carefully washed with alcohol or some disinfecting solu- 
tion and the syringe carefully sterilized. Nowadays the serum is ob- 
tainable in clean hermetically sealed syringes, rendering their steriliza- 
tion unnecessary. Children under two years of age should receive from 
3 to 5,000 units of antitoxin, and those over this age from 5 to 10,000 
units. Equal or smaller doses may be given after about eight hours, if 
no improvement is observed. The antitoxin injection is somtimes fol- 
lowed (within from two days to two weeks) by an erythema or urticaria- 
like eruption which usually disappears without any special treatment. 
In malignant cases or in those seen late, double doses should be adminis- 
tered at once and, if necessary, repeated, or the antitoxin may be ad- 
ministered intravenously (after warming the antitoxin in its container 
in hot water). The effect of the serum is very beneficial, nay, sometimes 
magical. After a temporary rise, the fever often falls by crisis, the 
pulse improves, the membranes loosen and disappear, and the whole as- 
pect of the case sometimes changes completely for the better, within 
from eighteen to twenty-four hours. However, notwithstanding all that 
was said in favor of the antidiphtheritic serum, it is not always advisa- 
ble to depend upon the serum alone. 

As diphtheria is originally a local affection and the secretion and ab- 
sorption of the metabolic products (toxins) occur from the local lesion, 
the urgency of the immediate destruction of the bacilli at their point 
of entrance is self-evident. This is best accomplished by the different 
germicides and solvents, such as peroxide of hydrogen, strong solu- 
tions of carbolic or salicylic acid, 20 per cent to 50 per cent solutions 
of resorcin in alcohol, tincture iodine, argyrol or solargentum (20 per 
cent), or the carbol-camphor solution referred to on p. 295. Milder so- 
lutions of the same preparations should be used also for cleansing the 
nose, even in the absence of any lesion there. The local treatment 
should be repeated every two to four hours and continued until total 
disappearance of the acute symptoms of diphtheria. 

I£ Glyeerit. Papain. 3 iv 

Acid Carbolici aa 15.0 

Pulv. Camphorae gr. x 0.65 ' 

Alcoholis 3 ii 8.0 

Glycerini q. s. f 3 ii 60.0 

This is applied to the throat by means of a cotton swab every two 
hours — changing the swab each time — diminishing the frequency of 



SPECIFIC COMMUNICABLE DISEASES 373 

applications with the abatement of the severity of the symptoms. 
Flushing of the throat with a warm solution of boric acid or bicarbo- 
nate of soda (2 drams to 1 quart of water) by means of an irrigator 
is very beneficial. 

The third indication, to increase the power of resistance of the pa- 
tient, should be met by an abundance of nutritious, easily digestible 
food, stimulants and hematinics. Feeding of the little patient is as 
difficult as it is important. As a rule, total anorexia prevails and it 
requires a great deal of patience and tact to induce the child to swal- 
low a few mouthfuls of milk, beef juice, ice cream, fruit juices, etc. 
Still, much may be gained by administering the nourishment in small, 
frequently repeated quantities, and in small children, if need be, by 
rectal alimentation (peptonized milk). As a food and stimulant good 
wines and cognac are of inestimable value in diphtheria, especially in 
the septic variety. In malignant cases it should be given well diluted 
in large, frequently repeated doses (1 to 2 drams every two hours), 
preferably by mouth, and in urgent cases, cognac in smaller doses 
also hypodermically. It is advisable to employ mild stimulation from 
the earliest inception of the disease, and to continue it for weeks after 
in order to obviate — at least to a certain extent — sudden heart failure. 
A useful combination which acts both as stimulant and hematinic, is 
the following: 

B; Strychnines Sulph. gr.% 0.01 

Liq. Ferri et Ammonii acetatis 3 ii 60.0 
M. 
S. — One teaspoonful, diluted, in sweetened 

water, every six hours. 

Whenever the local as well as systemic effect of iron is desirable, 
the iron and myrrh mixture referred to on p. 391 answers the purpose 
admirably. Any untoward symptoms arising should be combated ac- 
cording to indications. In heart weakness, strychnine and digitalis 
should be pushed to full tolerance. 

In laryngeal diphtheria without nasopharyngeal lesions, the local 
treatment outlined for the pharyngeal involvement may be dispensed 
with. Occasional cleansing of the nose and throat with a 5 to 10 per 
cent solution of argyrol, silvol, or solargentum or Dobell's solution, 
however, is useful as a preventive measure. It is of advantage also to 
have the patient inhale medicated vapors, such as the following: 

I> Acid. Carbolici 3 ss 2.00 

Eucalyptol 3 i 4.00 

Tr. Benzoini Compound q.s. ad f §ii 60.00 
M. 
S. — One teaspoonful in a pint of hot water, for inhalation. 



374 DISEASES OF CHILDREN 

With early administration of antidiphtheritic serum the laryngeal 
stenosis rarely attains such severity as to demand relief by intubation 
(see p. 376) or tracheotomy (see p. 381). Mild paroxysmal attacks 
of dyspnea often yield to emesis (% dram of wine of ipecacuanha, 
or 1/20 grain of apomorphine hydrochlorate), and a small dose of 
morphine (1/50 grain) and atropine (1/500 grain). But if these rem- 
edies fail, intubation or tracheotomy should be resorted to. It is always 
preferable to intubate (or tracheotomize) early rather than late. When- 
ever the dyspnea is steadily increasing in intensity and the temperature 
rises, this life-saving measure is indispensable, and procrastination is 
apt to prove fatal. 

Differential Diagnosis 

1. Pharyngeal Diphtheria. — (a) Pseudomembrane. — In pharyngeal 
diphtheria the pseudomembrane appears as a small, uneven, grayish- 
white, slightly elevated patch upon the inner or faucial surfaces of the 
throat. The deposit — which contains diphtheria bacilli — augments by 
quick spreading, reaching within a few hours the posterior wall of the 
pharynx, and, in severe cases, the Eustachian tubes, nares, and, more 
rarely, the conjunctiva. Anteriorly the pseudomembrane attacks the 
palatal arch and uvula. It may spread downward into the larynx or 
alimentary canal. The surrounding uncovered areas are grayish in color, 
due to overcrowding of leucocytes, nuclei, and mucus beneath. The ton- 
sils, as a rule, are but slightly enlarged. The deposit, if removed^ leaves 
a raw, bleeding surface and reforms rapidly. 

In follicular amygdalitis the deposit begins as one or more white small 
pellicles upon the middle or anterior portion of the tonsil. The pellicles, 
at first distinctly isolated, gradually coalesce, forming elevated patches. 
They are limited to the tonsils, may easily be removed, and reform slowly. 
The tonsil, usually one, is moderately enlarged, sometimes previous to 
the appearance of the deposit. 

In parenchymatous amygdalitis the tonsil is greatly enlarged, often dis- 
placing the uvula. It is bluish in color and doughy in consistency. The 
deposit, at first white, soon becomes yellowish, resembling the "point" 
of an abscess. 

In necrotic amygdalitis or Vincent's angina the tonsils are moderately 
have a tendency to burst and leave superficial ulcers. This form of 
amygdalitis is at times accompanied by stomatitis. Otherwise it resem- 
bles follicular amygdalitis. 

In necrotic amygdalitis or Vincent's angina the tonsils are moderately 
enlarged and the deposit lies deeply imbedded within the structure of 
the mucous membrane. The deposit, if removed, leaves behind a deep 



SPECIFIC COMMUNICABLE DISEASES 375 

u l cer — sometimes gangrenous — surrounded by a distinct red zone; it 
spreads, as a rule, from one tonsil to the other by way of the anterior 
pillars and palatal arch, frequently attacking also the uvula. 

Vincent's angina and septic sore throat are best diagnosed by a culture 
from the tonsillar deposits. 

(b) Submaxillary Glands. — The submaxillary glands in diphtheria 
are greatly involved. They are large and hard, assuming the shape 
of a large walnut, and can easily be seen protruding from the angle of 
the jaw. They are very painful to the touch. 

In follicular and herpetic amygdalitis the glands are moderately en- 
larged, softer in consistence and less painful to the touch than in diph- 
theria. 

In parenchymatous amygdalitis the glands are moderately enlarged and 
diffuse, the swelling often extending as high as the ear. 

In necrotic amygdalitis the glands differ but slightly from those of 
diphtheria and cannot be relied upon as a differential point of diagnosis. 

(c) Early Constitutional Symptoms. — Except the presence of albu- 
min in diphtheritic urine, none of the early constitutional symptoms 
are characteristic of diphtheria. Indeed, they are frequently less 
pronounced in diphtheria than in any other throat affections, unless 
the former is complicated by streptococcic infection. The temperature 
in diphtheria, as a rule, is moderate, about 101° to 103° F., and con- 
tinuous. The pulse is feeble and quick and soon gives signs of exhaus- 
tion. The face, as a rule, is pale. Swallowing is difficult, but not 
very painful, due to partial degeneration of the muscles of deglutition 
and their nerve supply. Albuminuria is invariably present from the 
earliest beginning of the disease and is of great significance in the 
differential diagnosis. 

In the various forms of amygdalitis the temperature is quite high, 
especially toward evening, often reaching 105° F. The face is flushed. 
Deglutition is painful and difficult as a direct result of soreness and 
sensitiveness of the tonsils. Albuminuria is usually absent. 

The diagnosis of scarlatinal angina is at best very difficult. It may 
be taken for granted that the primary amygdalitis of scarlet fever is 
scarlatinal in nature, and that the sore throat which sets in several days 
after is diphtheritic. It should be left, however, to the bacteriologic test 
to clear up the diagnosis. 

2. Laryngeal Diphtheria. — Laryngeal diphtheria can only be mis- 
taken for nondiphtheritic membranous laryngitis (see p. 310), and 
spasmodic laryngitis. In both of these affections, however, the Klebs- 
Loeffler bacillus is absent. 



376 DISEASES OF CHILDREN 

Intubation in Laryngeal Diphtheria 

Before discussing the subject in question I deem it opportune again 
to recall the great services rendered by the master of intubation, the 
late Dr. Joseph O'Dwyer, of New York, who after numerous failures 
and discouragements finally succeeded in presenting to the world a 
priceless gift in the form of an intubation set, which has saved multi- 
tudes of children from gradual, agonizing death. Before this mar- 
velous invention was fully accepted by the medical profession, Dr. 
O'Dwyer had been frequently humiliated by incompetent and possibly 
envious critics, rather than honored, remunerated, and decorated, by 
his state or country, or perpetuated in bronze or granite, as he surely 
would have been, had he been as successfully engaged in the acts of de- 
struction, in the art of warfare, instead of in a deed of mercy. 

My records of the past five years, during which time I have had 
the privilege of intubating sixty-eight children suffering from laryngeal 
diphtheria, show but one fatal issue. This favorable result was un- 
doubtedly due to the facts, first, that the physicians in attendance had 
promptly administered ample doses of antitoxin to neutralize the 
diphtheritic toxin ; and secondly, that the intubation was done early. 
It may be noted that all these children remained in their own homes, 
often in most undesirable surroundings, and without skilful nursing. 
Four of them lived out of town, requiring two or three hours' jour- 
ney to reach. To emphasize the absolute feasibility and perfect safety 
with which intubation can be performed even under the most ^trying 
conditions, we may briefly relate the following case: 

L. P., four years old, the son of Slavish parents in the poorest district of Perth 
Arnboy, N. J., had been ill for three days before consulting Dr. S. Finding in- 
volvement of the nasopharynx and larynx, he. immediately administered 10,000 units 
of antitoxin and prescribed other remedies ordinarily in use. During the night the 
child got very much worse and the laryngeal stenosis had assumed alarming in- 
tensity by the time we arrived there. Owing to considerable tumefaction and un- 
usual depth of the larynx, intubation was somewhat difficult, but the boy obtained 
prompt relief with introduction of the tube. After giving 10,000 units of anti- 
toxin and ordering absolute rest, we left the child, practically without any specific 
directions, under the care of the mother, who was entirely helpless and unable to 
understand our language. Five days later we returned for extubation, and, to our 
great amazement, we were met at the door by the little patient, tube still in the 
throat, but apparently perfectly happy. Extubation was comparatively easy, and 
the boy required no after-treatment whatever. 

This case, among several similar ones, has fully convinced me that 
intubation can be performed without hesitancy even in the humblest 
of homes without any preparations or skilful after-treatment. This 
optimism is not shared by a goodly number of clinicians, one group of 



SPECIFIC COMMUNICABLE DISEASES 377 

whom, discarding intubation entirely as a dangerous operation and 
preferring tracheotomy, with the certain dangers and disadvantages 
of hemorrhage, secondary infection, tracheal fistula, stricture of the 
larynx, delayed convalescence from a slowly healing wound, and a 
disfiguring cicatrix; and another group of physicians, who, though 
recommending intubation in preference to tracheotomy, are neverthe- 
less quite timid in accepting it as the operation of choice in all cases 
of laryngeal stenosis. They lay particular stress upon the risk of the 
tube causing ulceration of the larynx, or the danger of return or in- 
crease of the dyspnea, either by pushing false membrane before the 
tube or blocking it while in the larynx, and also of expulsion of the 
tube by coughing or otherwise. Now, we do not at all hesitate to say 
that those who claim intubation to be a dangerous operation never had 
the opportunity or inclination to learn the operation under the guid- 
ance of a competent instructor, nor have they given it a fair trial. In 
the many years of experience with intubation we have never met with 
the aforementioned difficulties, and believe that this is due, first, to the 
fact that with the early administration of antitoxin the virulent types 
of diphtheria of olden times are of very exceptional occurrence now- 
adays; and secondly, to the care and scrutiny in the selection of the 
cases and strict attention to the principles and technic as handed down 
to us by the late Dr. O'Dwyer. 

To begin with, we must be absolutely positive that the cases in ques- 
tion actually require intubation. On several occasions we have been 
invited to intubate children who, instead of suffering from laryngeal 
stenosis, were in reality in the last stages of pulmonary edema, com- 
plicating pulmonary or cardiac disease. Recently I was called to in- 
tubate a fifteen months old infant supposedly dying from diphtheritic 
laryngeal stenosis. The baby did have tonsillar diphtheria, but no 
trace of laryngeal involvement, the noisy breathing having been due to 
intense dyspnea accompanying myocardial disease. I declined to in- 
tubate, and advised heart stimulants. The parents of the child, how- 
ever, could not be reconciled to this view, seeing that the "baby 
was choking," hence insisted upon getting a throat specialist to in- 
tubate. This was done two hours later, with the result that the baby 
died during the operation. 

The next point of importance before proceeding with intubation 
is to be certain that the instruments are in perfect working order.* 

*A set of intubation instruments (O'Dwyer's) suitable for children up to the age of pubertv 
consists of six tubes, an introducer, an extractor, a mouth gag, and a scale of sizes. O'Dwyer's 
latest tubes are made of hard rubber lined with gold-plated metal. Each tube is supplied with 
an obturator, one end of which screws on the introducer. The tube is selected according to 
the age of the patient — the smallest size for the first year, the second for the second year, the 
third for from two to four years, and the others, successively for children two years older. It 
should be remembered that the tube must fit the larynx and the latter not be made to fit the tube. 



378 



DISEASES OF CHILDREN 



Particular attention should be paid to the construction and condition 
of the tube, more particularly that it be free from rough or sharp metal 
edges ; otherwise, when during the act of swallowing the epiglottis and 
upper end of the tube are pushed posteriorly by the backward pressure 
of the base of the tongue, and the lower end of the tube is pressed 
forward, the gliding movement of the rough tube is very apt to in- 
jure the anterior wall of the trachea and thus to produce the ulcera- 
tion of the larynx previously spoken of. We must also note that the 
obturator fits snugly, and that the tube selected corresponds to the size 
of the child's larynx. 

After having ascertained these details to our entire satisfaction we 
may then proceed with the operation. The patient is placed upon a 
strong table, and, from shoulders down, wrapped tightly in a small 




!. — Instruments for intubation. (Dr. O'Dwyer's.) 



sheet or blanket, fastened by several strong safety pins. An assistant 
standing at the head of the table inserts a mouth gag in the left angle 
of the child's mouth, well back between the teeth, and opens the gag 
as wide as possible without using undue force. The same assistant 
steadies the patient's head and holds the gag in place. The operator, 
standing to the right and in front of the patient, holds the introducer 
lightly between thumb and fingers of the right hand, with the thumb 
resting just behind the button that serves to detach the tube, and the 
index finger in front of the trigger underneath. The index finger of 
the left hand is now gently passed into the pharynx, down to the 
beginning of the esophagus, and by bringing the finger forward in the 
median line and raising and fixing the epiglottis, the tube (threaded 



SPECIFIC COMMUNICABLE DISEASES 



379 



with silk to prevent it from slipping into the stomach in case it is 
wrongly put into the esophagus) is gently introduced along the left 
index finger into the larynx. The left index finger is then quickly 
put on the shoulder of the tube, and the introducer (with obturator) 
is withdrawn after pushing its upper button forward. After the tube 
has been securely pushed home the mouth gag is removed, but the 
silk thread is left in the tube for about ten minutes, until it has been 
ascertained that the d3 T spnea is relieved and no loose membrane is 




Fig. 89. — Mode of feeding after intubation. 



crowded down in the lower portion of the trachea. In removing the 
thread, the finger should be reinserted to hold the tube in place. As 
a rule, introduction is followed by an active spell of coughing, which 
generally expels mucus and bits of membrane that may have been 
lodged in the upper respiratory tract. Should we fail, however, to 
relieve the dyspnea, it is advisable to remove the tube immediately by 
pulling the thread, to induce emesis and expulsive coughing by tick- 
ling the child's palate and throat with spoon or finger, and then to re- 
introduce the tube, or, if the case be very urgent, to use a smaller tube 



380 DISEASES OF CHILDREN 

temporarily. There is never any danger in repeated intubation, or 
even failure to intubate, provided the operation is performed very 
gentry — more particularly so as not to force a false passage — and the 
index finger is not allowed to rest upon the upper portion of the lar- 
ynx too long, so as to obstruct the air passage. 

The after treatment consists in keeping the patient quiet, preferably 
in a recumbent posture, application of an ice collar around the neck, 
and administration of antitoxin (if needed) and small doses of bro- 
mide, strychnine, and strophanthus. Feeding may be resumed a few 
hours after intubation: in babies, breast or cow's milk in small quan- 
tities, by means of a spoon; in older children, semisolid substances, 
such as custards, wine jelly, junket, soft-boiled egg, ice cream, and the 
like. Small pieces of ice may be given instead of water. It is often 
of advantage to feed the child with the head lower than the body 
(Fig. 89). 

With the absolute subsidence of the dyspnea and temperature, 
which usually occurs in from three to seven days, we may proceed with 
extubation. It is always advisable to have another tube ready for 
immediate reintubation in case removal of the tube is followed by 
return of intense dyspnea. For extubation the patient is prepared in the 
same manner as for intubation. The extractor is guided along beside the 
left index finger in the same manner as the intubator and very gently 
inserted into the aperture of the tube. The engaging terminal blades 
of the extractor are opened by lightly pressing upon the upper arm of 
the extractor, and the latter is then promptly withdrawn from the 
throat. This maneuver is not always easy, but even repeated fail- 
ure will do no harm, provided no force be employed. Occasionally 
one succeeds in removing the tube by "stripping" the larynx from 
below upward with one hand, at the same time grasping the head of 
the tube between the index and middle fingers of the other hand. 

As a rule, these procedures end the operation. On rare occasions, 
however, there is an immediate return of the asphyxia. In this event, 
unless the dyspnea resumes extraordinary gravity, we may administer an 
emetic (apomorphine) or minute doses of morphine and atropine hy- 
podermically, and spray the throat with a 1 or 2 per cent solution of 
cocaine until the spasmodic stenosis has been relieved. 

I recall but two instances where I was obliged to reintubate three 
times, and one of them failed to show diphtheria bacilli in the throat 
after repeated laboratory examinations. In these cases, which are 
generally spoken of as "retained intubation tubes," we usually rem- 
edy the trouble by gradually introducing larger tubes (anointed with 



SPECIFIC COMMUNICABLE DISEASES 381 

vaseline) with each reintubation and by local attention to the nose and 
throat. 

To counterpoise the admonition frequently given, " never to intubate 
patients who are extremely asphyxiated" (E. W. Goodall, Intern. Med. 
Ann., 1907), we may be permitted to relate the following instructive 
experience : 

J. D., five and a half years old, had been coughing croupy for three or four 
days, and, as the parents were poor, was treated by them with the usual home reme- 
dies. In the middle of the night his condition became so alarming that they hurried 
for a neighboring physician. Finding that the boy was suffocating from diphtheritic 
laryngeal stenosis, the doctor promptly summoned me to perform intubation. As I 
entered the dingy and foul-smelling room I was greeted with, " It is too late, Doctor. ' ' 
Indeed, the boy was actually in the last stage of asphyxia, his face bluish black, his 
eyes protruding and suffused, his breathing suspended, and his entire body per- 
fectly limp — apparently dead but for a barely audible fluttering of his heart. I 
remarked to my colleague that since we were not going to be paid for our visit 
anyhow, we might as well gain something from the additional practice in intubation. 
Thereupon I quickly inserted a tube in the boy's larynx, carried him to the front of 
an open window and injected }£ grain of strychnine hypodermically, while Dr. F. 
proceeded with artificial respiration. There was shortly a marked change for the 
better and the child improved so rapidly that, after administering 10,000 units of anti- 
toxin, we were able to leave him under the care of his mother within about an hour 
after our arrival. I extubated six days later, and the boy recovered fully without any 
further attention. 

Tracheotomy 

This operation is indicated where intubation fails to give relief, 
whenever the larynx is obstructed by foreign bodies, edema of the 
glottis, tumors (e.g., multiple laryngeal papillomas, or compression by 
tumors of neighboring structures) and cicatricial constriction of the 
larynx. Unless there be enlargement of the thyroid, the low operation 
is to be preferred, and, according to Donald Guthrie, may be performed 
without loss of blood, if the directions here given are followed : 

The child is wrapped in a blanket or sheet to control its struggling and 
placed on the table. A pad of some sort is put under the shoulders, and 
the head is hung over the end of the table — steadied by an assistant. 
The operator stands at the right hand side of the child and, steadying 
the skin with the left hand, makes an incision in the midline of the neck 
from iy 2 to 1% inches long. The skin and the superficial fascia are 
incised and the wound is held open by a pair of catspaw retractors which 
should not be more than an inch in breadth. When the deep cervical 
fascia is cut, the parallel branches of the anterior jugular veins are seen 
in the wound. The retractors are reset to pull these veins aside, and the 
sternohyoid and sternothyroid muscles are separated by blunt dissection. 



382 DISEASES OF CHILDREN 

If care can be exercised during this step of the operation, the muscles 
can usually be separated without injury to the thyroid ima beneath. 
The retractors are again reset, the left blade holding aside the skin, the 
fascia and the two muscles, and the right blade the skin, fascia, the mus- 
cles and the thyroid ima vein. This exposes the trachea to view. It is 
incised, the child's head is straightened, and the tracheotomy tube in- 




Fig. 90. — Tracheotomy tube. 

serted. The tube should be removed from time to time in order to deter- 
mine if the child can obtain a sufficient supply of air through the larynx. 
When this is achieved the tube is removed for good. 

Scarlatina 

(Scarlet Fever, Febris Kubra) 

The more frequently one has occasion to observe and to treat scar- 
let fever, the more he appreciates the treacherous nature of the affection. 
Grave danger often lurks in the most benignly appearing attack, and 
dreadful surprises are not rarely encountered at a time when the pa- 
tient is apparently at the threshold of recovery. It may be so mild in 
one child as to entirely escape observation, and yet may give rise to 
a most virulent type of the disease in another child. It is highly con- 
tagious and infectious in all its stages, the contagium (which is still 
unknown) being transmitted from person to person, through a third 
person, disease carrier, articles in use, toys, food (infected milk), and 
possibly also through the air. Children of from two to seven years are 
especially prone to contract the disease, but it has been observed even 
in the newborn of mothers suffering from scarlatina just before de- 
livery, and also in adults. It prevails principally during the winter 
months. So-called surgical scarlatina is occasionally contracted after 
severe burns or surgical operations. As in other contagious and infec- 



SPECIFIC COMMUNICABLE DISEASES 



383 




Chart II 



384 DISEASES OF CHILDREN 

tious diseases, some individuals possess an inherent or acquired tempo- 
rary or permanent immunity against this disease. On the other hand, 
some children are highly susceptible to scarlatina and may have two 
or three attacks, sometimes even in the form of a relapse within from 
two to six weeks after the first attack (scarlatina recurrens). 

The incubation period of scarlet fever is ordinarily shorter than that 
of any other exanthematous febrile disease. As a rule, it lasts only a 
few days (varies from one day to one or two weeks), and rarely gives 
rise to distinct symptoms of the approaching disease. On the contrary, 
often in the midst of apparently good health, the patient vomits (usu- 
ally repeatedly), complains of fatigue, slight sore throat, and chilliness; 
and young nervous children are occasionally attacked by convulsions. 
The temperature rises up to 103° or 104° F., or higher; the pulse is 
greatly accelerated; the throat is deeply injected; the tonsils are some- 
what enlarged and covered with a slight mucopurulent or hemorrhagic 
deposit. Sometimes a transient, prodromal erythema is observed on dif- 
ferent portions of the body. The aforementioned symptoms continue 
for about twenty-four hours. By this time, or a few hours later, a bright 
red rash becomes visible on the neck, chest and nates and the flexor 
surfaces of the extremities. On close examination the eruption is found 
to consist of very fine, rose-red to deep-red dots separated by minute, 
pale areas of healthy skin. The scarlet points are not elevated above the 
surface. The rash disappears on pressure, and when the finger nail or 
a pencil is drawn across the reddened surface, a white line (t aches scarla- 
tinale) develops which remains in situ for a few seconds. This is due 
to increased contractility of the superficial arterioles. Or if a tight band 
is put around the upper arm we may shortly notice minute linear hem- 
orrhages at the bend of the elbow (Rumpel-Leede sign). Gradually the 
scarlatinal eruption spreads usually from above downward over the en- 
tire body. It is least marked upon the face, and the circumoral ring — 
a space extending from the alae nasi to the chin — is nearly always free 
from the exanthema. The affected skin is very itchy and often edema- 
tous. With the advent of the eruption the temperature rises, the sub- 
maxillary glands swell up, are hard and painful to the touch. Inspec- 
tion of the throat in the majority of cases reveals a follicular deposit 
upon the tonsils which shows a tendency to coalesce and to form necrotic 
patches. The tongue is coated, very gray, and its edges and tip are 
bright red. The papillae fungiformes soon project through the coating 
as red papules — "strawberry tongue." In accord with the height of the 
temperature, the patient is more or less thirsty, restless, delirious, re- 
fuses food, sometimes vomits; his urine is scanty, high colored, and usu- 
ally contains a trace of albumin. The symptoms thus far related repre- 




W 



PLATE VIII 
Angina Scarlatinosa and "Strawberry Tongue" 

(Courtesy of Dr. John Zahorsky.) 



SPECIFIC COMMUNICABLE DISEASES 



385 



sent the clinical picture of typical scarlatina during the first two or 
three days of the eruptive stage. As the disease advances the gray de- 
posit on the tongue is cast off, the entire tongue is more or less swollen, 
red, often fissured, and covered with thickened papillae. The deposit in 
the throat loses its tenacity, and sometimes falls off en masse, leaving be- 
hind raw, sometimes bleeding surfaces. The pulse and temperature 
(103 to 105° F.) continue quite high. Cases of considerable severity 




Fig. 91. — Fever curve of a ease of scarlet fever. 



present in addition marked debility; febrile, cardiac, systolic murmurs; 
slight enlargement of the liver and spleen and at times somnolence, delir- 
ium, with or without high temperature. On the other hand, mild cases 
by this time (fifth day) may be on the road to recovery, free from fever 
and rash, the patients being ready to be around and about. 

The stadium desquamativ um usually sets in four or five days after the 
appearance of the eruption, and depends somewhat upon the intensity of 
the exanthema, beginning earlier when the rash is pronounced. The peel- 



386 DISEASES OF CHILDREN 

ing may vary from fine branny scales to large patches of epidermis, the 
coarser scales being usually limited to the hands and feet. Occasionally 
the nails shed with the epidermis. The peeling may last from two weeks 
to as many months, or even longer. In uncomplicated cases desquama- 
tion is followed by decline of the symptoms and convalescence. 

Complications are quite frequent, and their appearance is usually 
manifested by recrudescence of the temperature after defervescence. 
Scarlatinal angina — a necrotic inflammation of the throat — heads the 
list. It is caused by streptococcic infection and differs clinically 
from true diphtheria in that it almost never spreads to the larynx 
nor causes paralysis. Occasionally it is associated with true diph- 
theria. 

The throat involvement may be grave right from the beginning 
of the scarlatina, but more frequently it develops between the third 
and fourth days, usually in the form of an aggravation of the previous 
condition. The glands at the angles of the jaws swell at times enor- 
mously, are very hard and tender. Inspection of the throat reveals a 
large yellow or gray exudate on the greatly enlarged tonsils, and often 
also on the posterior pharyngeal wall. Scarlatinal angina often extends 
also to the nose, giving rise to a fetid, brownish-yellow discharge, 
and occasionally to deeper destructive processes and even to necrosis 
of the nasal bones. Scarlatinal angina is a very malignant affection, 
and frequently leads to fatal termination as a result of gangrene 
of the throat, involvement of the neighboring blood vessels, purulent 
inflammation of the serous membranes (pleura, pericardium and men- 
inges), extreme prostration, and general pyemia. In some epidemics 
one is able to distinguish two additional types of angina : 1. The 
"pestilential form," characterized by mucopurulent, foul masses in the 
throat and nose, spreading of the gangrenous process to the mouth and 
the mucous membrane of the lips and cheeks with consecutive hemor- 
rhage, septicopyemic symptoms, increasing collapse, and fatal termina- 
tion within about one week. 2. "Lentescent scarlatinal diphtheroid, " 
which sets in about the sixth day of the disease with sudden rise of 
temperature, grave constitutional symptoms and intense swelling of 
the submaxillary glands. The local symptoms (which, by the way, are 
sometimes hidden!) in the nose and throat resemble those of true 
diphtheria, except that in scarlet fever there is a greater tendency to 
necrosis of the affected portions, and to perforation of the palate (as 
in syphilis). After stubborn persistence it quite frequently leads to 
fatal issue with symptoms of pyemia and asthenia. True diphtheria 
may be associated with any of the aforementioned forms of scarlatinal 
angina. An examination of the deposit for Klebs-Loffler bacillus, 



SPECIFIC COMMUNICABLE DISEASES 387 

therefore, is always opportune. Purulent otitis frequently arises 
as an immediate sequel of the nasopharyngeal involvement by extension 
of the inflammation through the Eustachian tube and tympanic cavity. 
It is manifested by the usual symptoms of otitis media: earache, rest- 
lessness, rise of temperature, congestion and bulging of the drum mem- 
brane, and, as a rule, rapid perforation of the drum by the pus. In 
a great many cases the otitis leaves no serious consequences behind; 
in some of them, however, especially in those in which the escape of 
pus is delaj^ed, scarlatinal otitis may lead to very grave consequences, 
such as deafness (in very young children deaf-mutism) mastoiditis, 
meningitis, etc. 

Another serious sequel of the throat affection is angina Ludovici, 
an inflammation of the submaxillary lymph glands and the surround- 
ing cellular tissue of the neck, extending from the submental region 
up to the mastoid process of the temporal bone. The inflammatory 
infiltration sometimes extends to the larynx and produces edema glot- 
tidis, and, by gravitation, the pus may enter the mediastinum and 
neighboring structures (leading to purulent pleurisy or pericarditis). 
It not rarely ends fatally with symptoms of septicemia, embolism or 
thrombosis. 

Among the earlier complications of scarlatina we may mention 
also pneumonia with or without pleurisy, rheumatism (myositis, sjno- 
vitis) and endocarditis. Ail of these complications are probably of 
septic origin. The pneumonia presents nothing characteristic, may 
be lobular or lobar in type. It usually runs a shorter course than 
primary pneumonia. Scarlatinal rheumatism occurs in two forms: 
Simple myositis, i. e., a localized muscular infiltration, with sensitive- 
ness on pressure, and vague "wandering" pain; and scarlatinal syno- 
vitis or arthritis which is manifested by pain, swelling and redness 
of the joints, especially those of the fingers and toes, rise of tempera- 
ture, and other constitutional symptoms. Sometimes several joints 
are affected by leaps. As a rule, scarlatinal rheumatism is benign 
in nature; occasionally, however, the joints may undergo suppuration, 
leading to general pyemia with fatal termination. 

In association with scarlatinal rheumatism, but often also without 
this, endocarditis forms a relatively frequent complication and sequel 
scarlatina. Indeed, the majority of cases of valvular heart disease in 
children, except, of course, those complicating primary rheumatic fever, 
are traceable to scarlatina. The endocarditis may at first be latent, 
and escape detection, and again, may usher in with very grave symptoms, 
run the course of ulcerative endocarditis, giving rise to emboli and 



388 DISEASES OF CHILDREN 

metastases in the liver, spleen, and kidneys, and end in sudden death 
or permanent valvular heart disease. 

The blood shows a pronounced lencocytosis, a marked increase of 
eosinophils (up to 15 or 20 per cent of all white cells) and, in se- 
vere cases, streptococci. 

The treacherous nature of scarlatina is most poignantly illustrated 
by the occurrence of nephritis as a complication. In the midst of 
apparently perfect health, at a time when the eruption has entirely 
subsided, either with or without any tangible cause (often after a 
slight error in the diet), the child is suddenly attacked by head- 
ache, dizziness, sometimes vomiting and convulsions, and examination 
of the urine reveals an interstitial inflammation of the kidneys. As 
the disease advances the symptoms enumerated under ''nephritis" 
(q. v.) are rapidly and fully established. The complication usually oc- 
curs between the end of the second and third weeks. Hence the im- 
portance of daily examination of the urine in all cases of scarlatina, 
irrespective of the type or degree of severity of the disease. The dura- 
tion of the nephritis varies greatly according to its severity, and the 
promptness with which it is discovered and treated. Ordinarily it 
lasts from two to four weeks and ends favorably, but relapses are not 
rare, and the nephritis may go on to chronic renal disease. In fact, 
scarlet fever, as a rule, forms the principal cause of chronic nephri- 
tis in children. Protracted scarlatinal nephritis often gives rise 
to hypertrophy of the left ventricle and occasionally also to dila- 
tation of the heart with consecutive symptoms of ruptured compensa- 
tion (recurrent anasarca, dyspnea, etc.). Genuine scarlatinal neph- 
ritis should not be confounded with the transient albuminuria not 
rarely observed during the first week of scarlatina, and which most 
probably is due to hyperpyrexia. As regards uremia, and its grave 
accompaniments, the reader is referred to "acute nephritis" (q. v.). 

More rare complications are the following: stomatitis ulcerosa and 
aphthosa, noma, gangrene and diphtheria of the genitalia, orchitis, 
vaginitis, gangrene of the skin and of the tapering extremities; various 
nervous disorders, such as meningitis, hemiplegia, aphasia, tetany, and 
psychoses; conjunctivitis, iritis, keratitis, choroiditis, neuroretinitis, 
retinitis albuminurica and sudden amaurosis (in one of our cases total 
amaurosis lasted over a week). 

Aside from the sequelae previously spoken of, scarlatina may be 
productive also of chronic purpura, chronic cutaneous affections (fu- 
runculosis), chorea, paralyses, marasmus, tuberculosis, etc. 

For the differential diagnosis see Table, p. 398. 



SPECIFIC COMMUNICABLE DISEASES 389 

The discussion of the subject in question thus far relates prin- 
cipally to cases of scarlatina of ordinary severity. In these cases the 
diagnosis is usually quite easy, and the prognosis, except in the pres- 
ence of serious complications, relatively favorable. We shall now en- 
deavor to emphasize some of the numerous atypical forms. 

Occasionally scarlatina is associated with an atypical eruption. In- 
stead of the fine scarlet rash there may be variously sized papules or 
wheals upon a reddened base; minute vesicles (scarlatina mill ares) or 
pemphigus-like blebs. The exanthema sometimes evolves gradually, re- 
quiring several days instead of hours as is the case in typical scarlatina. 
The rash may appear localized with intervening larger portions of nor- 
mal skin (scarlatina variegata). Finally, there may be genuine scarla- 
tina, with typical angina, nephritis, and even slight desquamation, with- 
out any exanthema (scarlatina sine exanthema) . The diagnosis in all 
such cases is extremely difficult, and sometimes impossible, unless at the 
same time typical scarlatina prevails in the immediate surroundings, and 
the other symptoms point strongly toward this disease. 

The course of the attack also may present great variations. It may 
be so very mild and brief as to escape observation, or run a mild, but 
protracted course, and remain free from complications. In the latter 
group of cases the temperature may be low, or remittent, with evening 
remissions and morning exacerbations (typus inversus). Fever may 
be absent entirely even in severe cases. Sometimes the temperature is 
very high (hyperpyretic scarlatina) from the beginning, giving rise 
to delirium, convulsions, etc., but subsides again after a few days, leav- 
ing the patient apparently unharmed. At other times, very high tem- 
perature is characteristic of malignant scarlet fever. 

Scarlatina maligna, gravissima s. fulminans, fortunately is not of 
very frequent occurrence. In the majority of instances the grave 
manifestations are in full bloom within the first twenty-four hours of 
the onset of the attack. The child is suddenly seized with vomiting, 
rigors, delirium or convulsions, the temperature rises to 106° F. or 
even higher. The pulse is weak, rapid and irregular. Sudden collapse, 
coma, eclampsia and death follow in rapid succession (often within 
twenty-four hours). In another group of cases the course is more pro- 
tracted, and typhoid in character. The temperature is not as high as 
in the aforementioned class, but is marked by evening exacerbations ; 
the tongue is dry, the lips and teeth are covered with sordes, the ab- 
domen is very tympanitic, and the stools are watery. The submaxillary 
glands are enormously enlarged. There are also signs of blood disso- 
lution, extensive hemorrhages from the nose, gums, and stomach, which 
greatly enhance the (fatal) exhaustion. The rash is usually of a vio- 



390 DISEASES OF CHILDREN 

let color and hemorrhagic spots are scattered over the surface of the 
bod}^. This form of scarlet fever is often spoken of as " septic, hem- 
orrhagic scarlatina." 

Appreciating the unreliability of the initial manifestations, the un- 
certainty in the further symptomatology, the diversity of the course 
of scarlatina and its great tendency toward grave complications and 
sequelae, it is prudent always to be very guarded in expressing an 
opinion as to the outcome of the disease, no matter how mild (or 
severe) the attack. The mortality varies in different epidemics, from 
4 to 40 per cent, and depends partly upon the age (it is high in chil- 
dren under four and over ten years old) of the patient and principally 
upon the number and severity of the complications and sequelae. 

Treatment. — In view of the high mortality it is essential to institute 
prompt prophylactic measures from the very inception of an attack 
of scarlatina. Rest in bed is indispensable even in the mildest cases, 
and should be enforced for at least two weeks (much longer in severe 
cases) from the beginning of the illness. For about the same length 
of time the diet should be restricted, avoiding all such articles of food 
as are apt to upset the alimentary canal and to irritate the kidneys. In 
the active stage of the disease the diet should consist of milk only, and, 
as the symptoms abate, light cereals, and thin broths may be added ; 
in older children also small quantities of toasted bread and butter, 
fish (boiled), chicken, soft-boiled eggs, and similar light food — all 
free from salt and spices. Easily digestible food should be continued 
for several weeks after subsidence of all traces of the disease. These 
procedures form the most potent means of prevention of renal and 
cardiac disease. 

In view of the frequency of ear complications every effort should be 
made, firstly by cleanliness of the nose and throat, to prevent infection 
of the Eustachian tubes, and secondly, infection arising, promptly to 
make a free outlet to the accumulated discharge. (See Otitis, p. 303.) 

As regards isolation, room ventilation, and disinfection, see p. 68. 

It is quite difficult to formulate rules for the active treatment of 
the disease. Every case is a law unto itself. We have no specific to 
combat the affection. Overdosing — but also underdosing — with medi- 
cines is to be deprecated. Very mild cases do best if left alone, ex- 
cept as regards prophylaxis. The recent attempts to favorably influence 
the course of scarlatina by means of convalescent serum are still in the 
experimental stage. 

The average case being usually of medium severity, an attempt will 
here be made to outline a mode of treatment which is best suited to 
meet ordinary indications. The patient should be put to bed in a 



SPECIFIC COMMUNICABLE DISEASES 391 

well-ventilated room (about 68° F.), the diet restricted to moderate 
quantities of water and a little milk — in the absence of vomiting. 
Since at the onset of the attack vomiting is usually very marked, 
no medication per mouth should be prescribed, except, perhaps, a few 
minute doses of calomel and bicarbonate of soda. To relieve high 
temperature and nervous irritation, we order a warm bath every three 
hours. The baths have also a very salutary effect upon the kidneys 
b}^ enhancing the elimination of the scarlatinal poison through the 
skin. Warm packs may be given instead of the baths. As soon as the 
vomiting has ceased, we increase the quantity of nourishment and di- 
rect our chief attention to the throat. The latter is swabbed every tw T o 
hours with from 5 to 30 per cent resorcin-alcohol solution or with the 
following : 



IJ Acid. Carbolici 




3 ss 


2.00 


Pulv. Camphorse 








Kesorcini 




aa gr. x 


0.60 


Alcoholis 




Sii 


8.00 


Glycerini 




q. s. f I ii 


60.00 


M. 






S. — Apply to the diseased 


parts by means of a 


cotton swab every two 


hours 


5. 





It is often very useful also to flush the throat several times daily 
with a warm boracic or bicarbonate of soda solution (1 dram to 1 quart 
of water). 

The nose should be cleansed freely with Dobells' solution or similar 
antiseptic. Often it will prove beneficial to instill in the nose once 
daily a 5 to 10 per cent solution of the newer silver preparations. In 
some cases the nose is heavily blocked with a profuse foul discharge 
which greatly interferes with respiration; in this event relief may be 
afforded by introduction of soft rubber catheter tubing, reaching 
from the nares down to the posterior nasopharynx. If dysphagia and 
tonsillar swelling are marked, we prescribe moderate doses of sodium 
salicylate, or one of the newer salicylate preparations, and the follow- 
ing mixture : 



1* Tr. Ferri Chloridi 




Tr. Myrrhae 




Potassii Chloratis aa 3 ss 


2.00 


Glycerini q. s. f § ii 


60.00 


M. 


S. — One teaspoonful every three hours, for 


child four years old. 





With the aforementioned therapeutic measures we are ordinarily 
successful favorably to proceed with the case up to the fifth day, — 



392 DISEASES OF CHILDREN 

the time when "scarlatinal diphtheria" is prone to appear. As it 
is almost next to impossible to differentiate scarlatinal from diphthe- 
ritic angina without a bacteriologic examination, it is sound and safe 
practice to administer diphtheria antitoxin in all cases of severe angina, 
especially if the exacerbation of the symptoms occurs by the end of 
the first week of the disease. We usually inject 5,000 units of anti- 
toxin at once and repeat the dose as indications arise. In malignant 
cases this can be combined with antistreptococcus serum or vaccine. 
The local and internal medicines should be continued, however, except 
bathing, which should be discontinued as soon as the temperature comes 
down to 100° F. The heart's action should be carefully watched, and 
any irregularity or debility detected, promptly treated by means of 
moderate doses of strychnine, digitalis or strophanthus. The latter 
two preparations are particularly useful in secondary involvement of 
the heart muscle. With the dietary and hygienic precautions taken one 
is seldom confronted by grave scarlatinal nephritis. Ordinarily, the 
symptoms are limited to slight albuminuria with occasional casts and 
blood cells, which readily disappear upon the administration of a few 
doses of calomel and alkaline diuretics and diaphoretics, or urotropin 
in 2 to 5 grain doses three times a day, high flushing of the bowels 
and a few hot baths. But, as already suggested, occasionally the 
uremic manifestations are extremely violent (delirium, convulsions, 
coma, etc.), resisting all sorts of medication, and growing worse from 
hour to hour. In these uremic conditions two therapeutic measures 
have proved to us of particular benefit: (1) Morphine and atropine 
hypodermically ; (2) lumbar puncture. For a child four years old we 
may administer 1/20 grain morphine and 1/500 grain atropine, to be 
repeated once or twice within twenty-four hours. In very bad cases 
both of these measures should be employed simultaneously. Their 
effect is often magical. 

Where the uremic symptoms are slight, bromide with or without 
chloral per mouth or per rectum suffice to relieve the nervous symp- 
toms. As to the management of protracted cases of nephritis, see 
"Nephritis". 

Simple transient scarlatinal myositis calls for no specific medication. 
On the other hand, arthritis demands prompt attention, since in the 
majority of instances it is a manifestation of sepsis and if left alone 
is apt to lead to general pyemia. The salicylates internally and ich- 
thyol externally seem to influence it very favorably, and where these 
measures fail and pus forms we should resort to a free incision and 
drainage— but not too hastily. The same holds true for cervical or 



SPECIFIC COMMUNICABLE DISEASES 393 

submaxillary adenitis which, though assuming very large dimensions, 
does not always suppurate. 

For suggestions as to the treatment of the remaining, less common 
complications of scarlatina, the reader is referred to the discussion 
of the respective diseases. 

An extremely difficult problem confronts the attending physician 
when called upon to treat a case of malignant scarlet fever. Do what 
you will, the treatment is seldom of any avail. Early administration 
of polyvalent antistreptococcic and antidiphtheritic serum sometimes 
saves life, and should always be employed, regardless of bacteriologic 
findings in the nasopharyngeal discharges. The same holds good for 
lumbar puncture, if meningeal symptoms predominate. High tem- 
peratures failing to yield to hot baths should be reduced by cold 
(80° to 90° F.) packs or baths. The heart should be kept actively stim- 
ulated by strychnine, strophanthus, digitalis, caffeine, diuretin, and 
suprarenal extract, the latter especially in hemorrhagic complications. 

During convalescence particular attention should be paid to the ali- 
mentary tract and skin. The bowels should be looked after, and stuff- 
ing the child with sweets, heavy meats, and alcoholic ' ' tonics ' ' strictly 
forbidden. The patient should be warmly clad and wear flannel or silk 
next to the skin. Exposure to sudden atmospheric changes should 
be avoided. 

To facilitate desquamation, the child should be given a hot soap 
bath every two or three days followed by oil inunction to prevent 
free distribution of the scales. The following combination is quite 
serviceable, and may be employed also in the eruptive stage of the dis- 
ease to relieve itching and burning of the skin : — 



Thymolis 










Acid. Carboliei 






aa. gr. x 


0.65 


Alcoholis 






3ii 


8.00 


Glycerini 






q. s. f 5 ii 


60.00 


M. 










— For external 


use, 


p. r. 


n. 





When desquamation is completed and there is otherwise no con- 
traindication, the patient may be allowed out of doors. Cod liver oil 
with the syrup of the iodide of iron and a sojourn at the seashore have 
proved very helpful to rapid recovery. 

The patient is "contagious" for at least six weeks from the onset 
of the disease, and hence should not be permitted to mix with other 
children for that length of time, or longer, if desquamation continues, 
or discharges from the nose, throat, vagina, etc., are present. 



394 DISEASES OF CHILDREN 

The Fourth Disease" 

( Dukes ' Disease) 
The existence of this affection is still awaiting authoritative con- 
firmation. Some authorities maintain that it is merely a mild form 
of measles or scarlet fever. It begins after an incubation period of 
from six to fourteen days or longer with very mild febrile symptoms 
and an efflorescence on the face, including the circumoral ring. The 
next day the rash spreads, grouped in a sort of lacework arrangement, 
to the extremities and trunk. The course of the affection is conspic- 
uous by absence of any severe symptoms and usually terminates fa- 
vorably in from five to eight days, without any specific medication. 
Desquamation is copious and may last several weeks. Dukes' disease 
does not confer immunity against other exanthemata. 

Varicella 

(Chickenpox) 

The identity of the causal microorganism of varicella is still unknown. 
It is absolutely proved, however, that it has nothing in common with 
the infectious agent of smallpox, — hence an attack of chickenpox con- 
fers no immunity against the former affection. The disease is com- 
municable from person to person, through an intermediate person, 
through fomites, and the air. Children of from two to ten years of age 
are especially prone to contract the disease, but it is not rarely observed 
also in very young infants, and in children over ten, and even- adults 
are not entirely exempt from it. One attack does not confer absolute 
immunity against another one. 

The incubation period lasts about two weeks, the last few days 
showing slight prodromata. Occasionally the symptoms of invasion are 
moderately severe. There may be vomiting, angina, conjunctivitis, 
transient erythema, considerable rise of temperature preceded by chills, 
and in small children, convulsions. The eruption, which appears 
usually in small or large crops without any characteristic grouping 
simultaneously upon several portions of the entire body (also on the 
scalp and the mucous membrane of the mouth and throat) is fully 
established within twenty-four hours. At first the eruption appears 
in the form of slightly elevated rose-red spots, which disappear on 
stretching the skin. Within a few hours the center of the spot turns 
vesicular, filled with a clear fluid. The spots attain the size of a lentil 
or pea, but they may be larger, pemphigoid, and more rarely umbili- 
cated. On the third day the vesicles usually collapse and desiccate, and 

*Termed so, being additional to the three known diseases: Scarlatina, Rubella and Rubeola. 
It was first described by Dukes in 1900. 



SPECIFIC COMMUNICABLE DISEASES 395 

become covered by brownish-black crusts. The latter usually fall 
off on the fifth or sixth day, leaving slight red spots which soon disap- 
pear. Eepeated recurrences of new crops of the eruption in different 
stages of development (papules, vesicles, pustules and crusts), some- 
times as late as ten to twelve days after the onset, are not rare and 
often serve of signal value in the differentiation of varicella from 
variola, in which latter disease the eruption remains uniform and sta- 
tionary until the final stage of the disease. Occasionally the vesicu- 
lar content is turbid or purulent (usually as a result of infection 
by scratching), and when the pustules heal leave behind scars re- 
sembling "smallpox pits." Sometimes the vesicles burst early and 
give rise to erosions and ulcerations which, if occurring in the larynx, 
may be productive of attacks of dyspnea and, exceptionally, fatal 
laryngospasm. More frequently we meet, usually as a result of infec- 
tion, with multiple ulcerative and gangrenous processes of the skin 
— varicella gangrenosa — in which the vesicles terminate in deep, foul- 
smelling ulcers, and extensive gangrene of the skin. This form of 
chickenpox is most common in delicate, ill-nourished children and is 
apt to prove fatal. Complications and sequelae in the form of nephritis — 
nephritis varicellosa, pneumonia, pleuritis, pemphigus — varicella bullosa, 
multiple abscesses, pyemic processes (due to staphylococcic or strepto- 
coccic infection), icterus catarrhalis, dysentery, polioencephalitic mani- 
festations, marasmus and even tuberculosis are on record, but they are 
rather of unusual occurrence. Finally varicella is occasionally asso- 
ciated with other exanthemas (e.g., measles, scarlet fever). Very re- 
cently several clinicians have called attention to a curious relationship 
between varicella and herpes zoster and are inclined to the belief that the 
latter is an atypical manifestation of the chickenpox virus. This view 
is awaiting further confirmation. 

Treatment. — As a rule, varicella pursues a benign and brief course, 
free from high temperature, and any other constitutional symptoms 
and rarely calls for any therapeutic measures. Kest in bed, careful 
diet, and local cooling lotions (2 per cent of thymol in albolene) or oint- 
ments (zinc oxide with 1 per cent salicylic acid and thymol and phenol) 
to relieve itching usually suffice in ordinary cases. Cleanliness of the 
mouth and throat is important, as well as attention to the urine. For dif- 
ferential diagnosis, see Table, p. 398. 

Variola Vera. Varioloid 

(Smallpox) 
The history of smallpox is that of death and destruction. It is es- 
timated that, before Jenner's discovery of prophylactic vaccination, 



396 DISEASES OF CHILDREN 

one tenth of all the children died of smallpox. On the other hand, with 
vaccination and revaccination rendered obligatory in most of the civil- 
ized countries, the occurrence of variola in a child is almost unheard of. 
If it ever does occur in successfully vaccinated children, the disease is 
usually mild, modified in form — varioloid. 

Smallpox is an acute, highly contagious and infectious, endemic and 
epidemic disease, characterized principally by an eruption that passes 
through the stages of papule, vesicle, pustule and scab, the development 
of the pustule being accompanied by a secondary fever. 

The nature of the smallpox producing poison is still unknown. It 
is undoubtedly a microorganism that exists in the eruption and prob- 
ably also in the blood. Garnieri has described minute corpuscles 
which are regularly found in the cells of variola and vaccinia pus- 
tules, but while they may serve as a characteristic differential point 
from varicella and other pustular eruptions, they seem to be of no 
etiologic importance. The disease is most communicable during the 
pustular and desquamative stages — at which time mere entering the 
sickroom is said to infect one not protected by vaccination. 

After an incubation period of from nine to fifteen days, which 
as a rule, is free from any significant signs of illness, the patient is 
suddenly seized by a violent chill, fever, severe pain in the back, con- 
vulsions, delirium, prostration, and sometimes collapse and death — 
long before the appearance of the eruption. An initial exanthema may 
appear at this time, in the form of an erythema or hemorrhagic spots, 
upon the trunk and extremities, more particularly on the anterior sur- 
face of the thigh (the so-called Simon's triangle). This mode of onset 
and termination is quite common in variola vera, affecting children un- 
der three years of age. Some cases survive until the appearance of a pap- 
ular exanthema upon the buccal and pharyngeal mucous membranes, 
and then usually die from exhaustion ; others again — usually older 
than three years — succumb to the attack in the suppurative stage, or, 
rather rarely, recover after a painful and tedious convalescence. 

It is customary to distinguish three types of variola vera: Dis- 
crete, confluent, and malignant (hemorrhagic). 

Discrete Form. — After the violent onset, the eruption, consisting 
of red, coarse spots, appears during the third day: first on the fore- 
head and lips, then on the head, trunk and arms, and last on the legs. 
Pressing the hand over the eruption, the latter imparts the sensation of 
velvet. The constitutional symptoms then abate, and the patient feels 
quite comfortable. On the fifth day of the disease the spots develop 
into papules; on the sixth into vesicles which soon become umbilicated. 
On the eighth day the vesicles are transformed into pustules which 



SPECIFIC COMMUNICABLE DISEASES 397 

emit a characteristic odor and on the ninth day they become entirely 
purulent and surrounded by a broad red band — the halo or areola. The 
face becomes swollen and the features are distorted. On the eleventh 
day it is usually found that pus oozes from the pustules which on drying 
forms the scab or crust. The latter falls off sometime between the seven- 
teenth to twenty-first days, leaving a red, glistening depression or pit 
which soon changes into a white cicatrix. With maturit}^ of the pustules 
eighth or ninth day) the symptoms observed at the onset return — 
secondary fever. This fever of suppuration is the most critical period of 
the disease. In favorable cases the secondary fever abates after a few 
days and convalescence follows. The stage of suppuration is very prone 
to be complicated by severe inflammation of the larynx, bronchi, lungs, 
and serous membranes. As further complications or sequelae we may 
mention stomatitis, noma, involvement of the eyes (phthisis bulbi), otitis 
media, dysentery and nephritis. 

Confluent Form. — This form is characterized by extreme violence 
of the constitutional symptoms and by the confluence of the eruption 
on certain portions of the body, such as the thigh and lower portion 
of the abdomen and the neck. 

Malignant or Hemorrhagic Form. — This type of smallpox is charac- 
terized by malignancy and irregularity of the symptoms, and coexist- 
ence of hemorrhages and petechias. In this form are included the so- 
called black smallpox {variola hemorrhagica pustulosa) which usually 
leads to fatal issue in the suppurative stage, and the fulminant type 
of smallpox (purpura variolosa) which ends fatally within from three 
to four days. 

In contrast to variola vera with its dreadful consequences stands vari- 
ola modificata or varioloid. The latter form of smallpox is usually ob- 
served in children rendered partially immune by previous vaccination 
or an attack of smallpox. Its course is shorter and milder than that 
of the other forms, the eruption is slight and devoid of suppuration, — 
hence its freedom from secondary fever and severe complications and 
sequelae. The mortality in varioloid varies between 8 per cent and 
10 per cent in infants and about 5 per cent in older children. 

Smallpox may be confounded, in the initial stage, with meningitis 
and, in the eruptive stage, with varicella and morbilli, especially morbilli 
hemorrhagici (q. v.). Meningitis can readily be eliminated after a day 
or two. The differential signs between smallpox and the other exan- 
themata are outlined on p. 398. 

Treatment. — If the patient with smallpox is seen early, vaccination 
should be performed at once ; it may modify the attack.* As a prophy- 



*In mild, doubtful cases vaccination may serve as a valuable aid in the diagnosis, for if suc- 
cessful, it would at once exclude the presence of smallpox. 



398 



DISEASES OF CHILDREN 



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SPECIFIC COMMUNICABLE DISEASES 399 

lactic measure it is also advisable to vaccinate all those who come 
and are apt to come in contact with the patient. Isolation, disinfection 
and preparation of the sick-chamber (the room shonld be kept dark 
by a deep-red shade) should be carefully carried out, in the manner 
prescribed on p. 69. The child should be confined to bed, and kept 
on a light but nutritious diet, and liberal supply of stimulants (wine, 
cognac). Special attention should be paid to disinfection of the 
mouth and nasopharynx (mild solution of potassium permanganate, 
or chlorate, peroxide of hydrogen). In high temperature and severe 
nervous phenomena prolonged warm baths or cool packs act favorably. 
To prevent itching and extensive pitting we may apply 5 per cent to 
10 per cent of ichthyol in equal parts of zinc and sulphur ointments, 
covered by some unctuous material to exclude the air. It is some- 
times necessary to tie the patient's hands to prevent scratching; and 
to administer hypnotics and anodynes for the relief of restlessness and 
pain. The child should be quarantined for about six weeks. 



3J Antipyrinse gr. xxiv 


1.60 


Tr. Cinchonas Comp. 3 iii 


12.00 


Syr. Aurantii § i 


30.00 


Aq. Aurantii q. s. ad f o ii 


60.00 


M. 


S. — One teaspoonful every four to six hours, 


for a child four years old. 


IJ Mentholis gr. v 


0.30 


Bisniuthi Subgallatis gr. x 


0.65 


Zinci Stearatis 3 ii 


60.00 


M. 


S. — Dusting powder to enhance desiccation of 


the eruption and to relieve itching. 





Typhus Abdominalis 

(Typhoid, Enteric Fever) 

Typhoid fever is an endemic, epidemic, and sporadic infectious 
disease due to the bacillus typhosus of Eberth. It is characterized by 
a continuous, typical fever, gastrointestinal catarrh, and a roseolar 
eruption. With the recent advances in bacteriologic diagnosis we are 
now certain that typhoid occurs almost as frequently in children (even 
fetal typhoid is on record!) as in adults, but owing to the mildness 
of the clinical picture it is frequently overlooked. The younger the 
child the greater the deviation of the symptomatology from the usual 
course. Thus, the onset is either more protracted (with symptoms of 
subacute gastroenteritis) than in the adult or very sudden with chills 



400 



DISEASES OF CHILDREN 



and high fever. In the newborn the symptoms may resemble those 
of sepsis. In older children the initial stage (pyrogenetic stage, first 
week) resembles that of adults and is marked by epistaxis, frontal head- 
ache, anorexia, fnrred tongue (later dry and brown), restless sleep, and 
gradual rise of temperature. The action of the bowels is not character- 
istic, and constipation may alternate with diarrhea (sometimes bloody). 
The fever reaches its height with the approach of the second week 
(fastigium), and varies in mild cases between 101° and 103° F. and in 
severe cases between 104° and 106° F., with morning remissions and 
evening exacerbations ("step curve"). Occasionally the typus inver- 
sus is observed, and not rarely the temperature is remarkably low 
throughout the entire course of the disease. The pulse is sometimes 



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Fig. 92. — Fever curve of typhoid fever in child four years old. 

very frequent (160 to 180) but rarely dicrotic. The urine responds to 
the diazo reaction, and contains traces of albumin. During this stage, 
the second week, the spleen is palpable, but not as distinctly as in adults. 
The roseolar eruption which usually appears about the eighth day on the 
abdomen, chest, back and limbs, is rather scanty and not rarely entirely 
absent. The typical eruption consists of small, elevated, rose-colored 
spots which momentarily disappear on pressure. They evolve in suc- 
cessive crops, each crop lasting about three days, and subside entirely 
after about ten days. Corresponding to the comparative mildness of the 
intestinal lesions, tympanites, iliac tenderness and gurgling are rarely 
marked. The same is true of the abdominal pain. If it is pronounced 



SPECIFIC COMMUNICABLE DISEASES 401 

we should look for a complicating cholecystitis, appendicitis, peritoni- 
tis or intestinal perforation. This last complication is most apt to oc- 
cur in the third week of the disease, and sets in either insidiously or 
abruptly, in the latter event with a sharp fall and abrupt rise of 
temperature (often preceded by a chill or vomiting), meteorism and 
abdominal rigidity, and subsequent appearance of fluid in the peritoneal 
cavity. This process is usually accompanied by a more or less marked 
leucocytosis. During the acme of the fever there are more or less 
marked nervous phenomena. Some patients are drowsy and apathetic; 
some are restless, shriek, and rave ; some suffer from defective hearing, 
hyperesthesia, insomnia, or semistupor, and, finally, others may be 
dull during the height of the fever but otherwise may be playful during 
the entire course of the disease. Children almost never present the 
status typhosus. As a rule, the blood gives a positive Widal reaction 
(q.v.). 

With the beginning of the third week (defervescent stage) there is a 
decided improvement in the general symptoms. The tongue begins to 
clear at the edges, the appetite returns (is often voracious), the temper- 
ature declines, as a rule, by lysis, and the grave nervous symptoms grad- 
ually abate. The temperature sometimes drops suddenly and remains 
normal or even subnormal. In severe cases, however, the fever may con- 
tinue (ambiguous stage) and with it all the other symptoms. Indeed, in 
older children the intestinal manifestations may become more pronounced, 
and hemorrhage from the bowels, perforation and peritonitis may super- 
vene. The usual bronchial catarrh may extend to the bronchioles and 
pulmonary tissue and lead to diffuse bronchopneumonia. Furthermore, 
improvement and recovery may be greatly delayed or entirely arrested 
by relapses, which are not uncommon between the third and fifth weeks, 
or by the following complications and sequela? : inflammation of the mu- 
cous membrane of the mouth (occasionally noma!), nasopharynx, and 
larynx; parotitis, otitis, cutaneous abscesses, periostitis, perispondylitis 
(typhoid spine) ; pericarditis, endocarditis, purulent arthritis, pyemia, 
thrombosis and embolism; paralyses (usually neuritis), chorea, apha- 
sia (lasts about a week), dementia, maniacal and melancholy states. 
The mental sequela? usually consist of merely temporary irritability, 
hypersensitiveness, disposition to cry, capriciousness and surliness. On 
the other hand, cases of permanent mental aberration are on record. 
Typhoid fever is sometimes associated with pertussis, morbilli, scar- 
latina and diphtheria, and in cases with a predisposition it is apt to be 
followed by pulmonary tuberculosis. Occasionally, typhoid is followed 
by a posttyphoidal desquamation of the skin, and during and after 
an attack there is frequently a marked longitudinal growth of the bones, 



402 DISEASES OF CHILDREN 

especially of the tubular bones of the lower extremities. As a result of 
it, the skin over these bones is sometimes transversely torn, the tears be- 
ing indicated at first by red lines, and later by white scars. 

The aforementioned grave complications and sequelae, are very rarely 
observed in children. As a rule, the prognosis except in very young 
infants, is favorable (5 to 10 per cent mortality), and, even after severe 
attacks, convalescence is comparatively rapid and uneventful. In young 
children the course of the disease is usually very brief, between twelve 
and fifteen days ; in older ones it is nearly the same as in adults. 

The morbid anatomic condition in the intestines is much milder than 
in adults ; ulcers are rare, and, if present, are small, superficial and iso- 
lated, hence they heal without leaving behind any cicatrices in the in- 
testines or any tendency to cicatricial contraction. 

In view of these marked deviations from the usual clinical picture, 
the diagnosis of sporadic cases of typhoid fever often presents great 
difficulties. It is apt to be mistaken for simple gastroenteritis — febrile 
stage of shorter duration, spleen, in uncomplicated cases, not enlarged, 
diazo reaction and "Widal 's blood test negative ; influenza with pro- 
nounced intestinal symptoms — febrile ' ' step ' ' curve absent, nervous phe- 
nomena less pronounced, catarrhal symptoms more marked, Widal's test 
negative, pneumonia — more sudden onset, more positive pulmonary 
physical signs, Widal's reaction negative, diplococcus pneumonias in the 
expectoration, neutrophilic leucocytosis ; acute miliary tuberculosis — ir- 
regular temperature with sweats, hectic flush, often tuberculous sputum, 
more protracted course, Widal's reaction negative; tuberculous meningi- 
tis — lower temperature ; slow, irregular pulse and respiration ; trough- 
shaped abdomen; malaria — usually intermittent or recurrent fever, ma- 
laria Plasmodium in the blood, influenced by quinine ; septic endocarditis 
— pronounced heart symptoms, chills with septic temperature, absence of 
Widal's reaction; tick or Rocky Mountain spotted fever — endemic of 
this region, characterized by a continuous, moderately high fever, severe 
muscular and arthritic pains, profuse petechial or purpural skin erup- 
tion appearing first on the ankles, wrists and forehead. Widal reaction 
is negative; typhus, spotted fever — general malaise, irregular pain 
throughout body, continuous fever, ending by crisis on the fourteenth 
day. Macular, petechial rash usually on the third to sixth day upon 
body and extremities. Weil-Felix's reaction is positive. Widal's re- 
action is negative. Occasionally typhoid begins with pain in the occiput, 
neck and back, opisthotonos, and other grave nervous phenomena, pre- 
senting the clinical picture of acute meningitis. The diagnosis in such 
cases is often almost impossible in the first few days of the disease. In 
doubtful cases the bacteriologic examination of the cerebrospinal fluid 



SPECIFIC COMMUNICABLE DISEASES 403 

for the diplococcus intracellularis, and of the stools and urine for the 
bacillus typhosus often proves decisive. 

Treatment. — As the contagium of typhoid fever resides principally 
in the gastrointestinal contents, it is imperative to disinfect the stools 
and vomitus thoroughly, as well as the linen and other articles in use 
that have been soiled by the discharges. Furthermore, by taking the 
precaution of boiling the drinking water or milk, excluding mosquitoes 
and flies from the sick-room, and by avoiding dissemination of the 
source of infection through soiled bath tubs, hands, etc., the disease 
may be limited to a single patient notwithstanding the intercommuni- 
cation between the patient and other members of the family. Strict 
isolation, therefore, is not essential. Prophylactic immunization! 

Typhoid fever is a self -limited disease and not controllable by any 
specific measures. The treatment, therefore, should be symptomatic, 
principally hygienic and dietetic. Cleanliness of the mouth and naso- 
pharynx, cool sponging of the body, with water or alcohol or vinegar, 
or if the temperature is high, cool packs or full baths, at a tempera- 
ture of from 80° to 90° F., and an ice bag to the head, usually suffice 
to make the patient fairly comfortable. During the first few days 
we may administer small doses of calomel and bismuth, and later 
dilute hydrochloric acid, pineapple juice and some good wine or cog- 
nac. Hexamethylenamine (2 to 5 grains) is useful during the entire 
course of the disease. In intestinal hemorrhage, an ice coil to the ab- 
domen and opium suppository (%o grain for every year of the child's 
age) will be found very efficient. When the hemorrhage is excessive, 
transfusion and surgical treatment should be instituted without delay. 
Rest in bed should be enjoined for at least two weeks after deferves- 
cence. The diet should be fluid (milk with tea, amply sweetened with 
milk sugar, or malt sugar, soups, light gruels, chicken broth, zoolak, 
egg with sherry wine, ice cream) during the acute course of the dis- 
ease, and semisolid thereafter, care being taken not to overfeed. 
Transition to a more solid diet should be very gradual. Relapses call 
for the same mode of treatment as the original attack. During con- 
valescence the different bitter tonics and iron are very desirable, and 
a sojourn at the seashore often works wonders. 

Complications should be carefully guarded against and immediately 
treated according to indications. Frequent change of position of the 
patient is usually effective to prevent serious pulmonary complications 
as well as decubitus. The skin should be hardened by alcohol, alum 
water, etc., and as much as possible protected by air cushions. The 
slightest abrasion of the skin should at once be treated by antiseptic 



404 DISEASES OF CHILDREN 

dressings (2 per cent solution of aluminum aceticotartrate). It is 
claimed that the external application of castor oil prevents and cures 
decubitus. Insomnia and excessive restlessness sometimes require 
hypnotics. 

Typhus Exanthematicus 

Typhus Fever, Spotted Fever, Ship Fever, Jail Fever, Camp Fever, 

Tabardillo (Mexico) 

Typhus fever is an acute infectious, endemic, epidemic and spo- 
radic disease of doubtful origin (the B. typhi exanthematici, Plotz, is as 
yet not generally accepted as the true cause), transmitted through 
the body louse and characterized by a discrete, maculated, petechial 
rash, and moderate fever, terminating by crisis in from ten to fourteen 
days. The prodromic stage lasts from a few hours to several days and 
is followed by severe headache, usually frontal, and pain in the back 
and extremities. The eruption generally appears on the fourth or fifth 
day, is rose colored or hemorrhagic, and scattered all over the body 
and more especially over the trunk and limbs. The spots do not dis- 
appear on pressure. The patients usually manifest a tendency to very 
rapid breathing, in the absence of other lung symptoms. In young 
children bronchopneumonia is not uncommon. The blood shows a 
marked leucocytosis. During the absence of an epidemic the diagnosis 
is often difficult until the termination of the disease (the sudden drop 
of temperature!) and may readily be mistaken for typhoid fever 
(Widal positive, see p. 86) and relapsing fever (recurrence of fever, 
spirillum in the blood). Positive Weil-Felix reaction (q.v.) is decisive 
of the diagnosis of typhus exanthematicus. 

The treatment is chiefly prophylactic (destruction of lice, fleas, etc.) 
and hygienic. Individual symptoms are treated according to indications. 

Typhus Recurrens 

(Febris Recurrens, Relapsing Fever, Spirochetosis) 

This affection is quite common in Europe, and in some African states, 
but is very rarely observed in the United States. It is due to a spiro- 
chete, varying in type in different countries, which was first described 
by Obermeier in 1873. Other types of the spirochete have since been 
demonstrated by Dutton, Carter and Novy. The disease is conveyed 
to men by ticks, bedbugs, fleas, lice and flies. It is characterized by two 
or more febrile paroxysms of six days' duration succeeded by afebrile 
intervals of equal length. The temperature ranges between 104° and 



SPECIFIC COMMUNICABLE DISEASES 405 

106° F. and comes down by lysis with profuse sweating and sound 
sleep. During the afebrile stages the patient seems in fairly good 
health. There is usually an enlargement of the liver and spleen and 
in severe cases profuse diarrhea, dysentery and hematemesis are ob- 
served. The spirochetes are circulating in the blood during the height 
of the fever. 

Treatment. — Prophylaxis is readily accomplished by extermination 
of the purveyors of the disease. The active treatment consists of intra- 
venous administration of neosalvarsan in doses from 0.1 to 0.4, to be re- 
peated every three or four days until the spirochete has been eliminated 
from the blood. Other symptoms are treated according to indications. 

Glandular Fever 

(Pfeiffer) 

Glandular fever is an infectious disease which sometimes occurs in 
epidemics, most frequently among children from two to eight years of 
age. The portal of entry of the infection is the rhinopharynx. Simul- 
taneously with a rapid rise in temperature (102° to 104° F.) there ap- 
pear more or less painful swellings of the submaxillary and cervical 
glands — which usually interfere with the movements of the head — 
redness of the throat, headache, sometimes vomiting and diarrhea, and 
occasionally enlargement of the spleen and liver. 

The fever usually disappears soon, sometimes within twenty-four 
hours ("one day fever"), but the glandular swelling persists for sev- 
eral weeks and exceptionally spreads to other lymph nodes of the 
body, e.g., bronchial (cough), esophageal (dysphagia) and retroperi- 
toneal (pain in the abdomen, especially on pressure). Occasionally 
this disease is complicated by nephritis, but the prognosis as a whole 
is good. 

In the early stages glandular fever may be mistaken for tonsillitis 
or parotitis. 

The treatment is symptomatic, calomel and the salicylates internally 
and a mild iodine ointment externally, ordinarily serving the purpose 
of relieving the pain, fever and swelling. Tonics and change of air in 
protracted cases. 

Malaria 

(Febris Intermittens, Febris Bemittens, Estivo-Autumnal) 

Malaria is endemic in the greater portion of the inhabited world, 
and is most prevalent in swampy tropical regions. No age is exempt 
from this disease. The exciting cause of malaria is the hematozoon 



406 DISEASES OF CHILDREN 

of Laveran conveyed to the human body principally by the bite of 
the Anopheles mosquito which has previously sucked the blood of a 
malarial patient and has acted as an intermediate host for the malarial 
parasite. The hematozoon enters the blood corpuscles and, after un- 
dergoing the different stages of development, the blood current — at 
this time giving rise to the characteristic chill or paroxysm. Vary- 
ing with the period of maturity and the species of the Plasmodium, 
the febrile attack may occur every day (quotidian) ; every two days, 
going on the third (tertian) ; every three days, going on the fourth 
(quartan) day; or may be more or less continuous with daily remis- 
sions (remittent or estivo-autumnal fever). Furthermore, several types 
of plasmodia or several generations of the same parasite may circu- 
late in the blood, and, by varying in the period of their maturity, 
may give rise to double tertian or quartan paroxysms daily or every 
other day at different hours. 

Intermittent Fever 

This form of malaria is characterized by the occurrence, at regular 
intervals, of paroxysms divided into four stages — premonitory, chill, 
fever, and the sweat. During the premonitory stage the patient com- 
plains of headache, lassitude, and nausea; he vomits, yawns, is irri- 
table and drowsy. Suddenly he is seized with a feeling of cold — the 
chill. The features become pinched, the lips blue, the skin cool and 
rough (cutis anserina) ; he shivers and shakes, and his teeth chatter 
while the thermometer in the axilla or rectum shows a decided rise 
of temperature. These phenomena may continue for from a few 
minutes to an hour or longer and are then gradually replaced by those 
of the hot stage, i. e., hyperpyrexia, flushed face, headache, full pulse, 
intense thirst, scanty urine, sometimes nausea, vomiting and severe 
nervous manifestations. The hot stage lasts from three to six hours 
or longer, and subsides gradually, being succeeded by more or less 
marked sweating, defervescence and rapid abatement of the other 
symptoms. The duration of the entire paroxysm is from six to twelve 
hours, after which time the patient is apparently well — until the return 
of a new attack which as already mentioned may occur every day, every 
two days or three days. 

This description corresponds with the symptomatology of typical 
intermittent fever, uninfluenced by medication, as it occurs in chil- 
dren over ten years of age. It is thus identical with that in adults. 
In younger children the course of the paroxysms presents numerous 
deviations. The prodromic and cold stages may be absent or of very 













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PLATE IX 
Life-Cycle of Plasmodium Vivax 

(After Grassi and Schaudinn ) 
The human cycle is above the transverse line, some rearranged by Kissalt and 
Hartmann. The cycle in the mosquito is beneath. 1 to 7, Schizogony; 1, sporozoite; 
2, entrance of sporozoite; 3 and 4, growth of the schizont; 5 and 6, nuclear division 
of the schizont; 7, formation of the merozoites; 8, merozoites; 9a to 12a, growth of 
the macrogametocyte ; 9b to 12b, growth of microgametocyte ; 13c to 17c, partheno- 
genesis of the macrogametocyte; 13a and 14a, maturation of macrogamete; 13b and 
14b, growth of the microgamete; 15b, microgamete ; 16, fructification; 17, Ookinete; 
18 to 20, entrance of the Ookinete into the stomach wall of the mosquito; 20 to 25, 
sporogony; 22 and 23, nuclear multiplication in the sporont; 24 and 25, formation 
of the sporozoites; 26, passage of the sporozoites to the salivary gland; 27, salivary 
gland of the mosquito with sporozoites (Magn. 1 to 17c, 1200 to 1 ; 18 to 27c, 600 
to 1.) Park: Pathogenic Bacteria and Protozoa. 



SPECIFIC COMMUNICABLE DISEASES 407 

brief duration. The chill may be replaced by grave nervous mani- 
festations, such as convulsions, or be indicated only by cyanosis of the 
lips and the tips of the fingers and toes. Sweating is slight or absent, 
or may be well marked and continue until the subsequent paroxysm 
of fever. Young children are rarely entirely free from discomfort during 
the intermittent stage. As a rule, they are exhausted, restless, have no 
appetite, etc. With repeated attacks of the fever there is marked 
swelling of the spleen and great diminution in the number of red 
blood cells. 

In view of the aforementioned deviations from the typical course 
of the paroxysms, the diagnosis of intermittent fever in young children 
often presents great difficulties. It is apt to be mistaken for tuber- 
culous (meningitis, lymphangitis, peritonitis, etc.) and pyemic (em- 
pyema, pyelitis, ulcerative endocarditis, otitis, etc.) processes, typhoid 
and influenza. A correct diagnosis, however, can usually be arrived 
at by exclusion, always bearing in mind the facts that in malaria the 
Plasmodium malarias or secondarj^ pigmentation of the blood cells 
is invariably present in the blood and that the course of the disease 
is greatly modified by full doses of quinine. 

Remittent (Estivo-autumnal) Fever 

This type of malarial fever is usually observed in the temperate 
zones, principally in the autumn. In institutions where large num- 
bers of children are congregated, it may occur in epidemic form and 
lead to grave diagnostic errors. It usually sets in suddenly with ma- 
laise and chilliness, followed by fever with exacerbations and remis- 
sions, the temperature during the latter, however, remaining con- 
stantly above normal. The other symptoms are very indefinite. As 
in all febrile diseases, anorexia, nausea, sometimes vomiting, head- 
ache, drowsiness and lassitude predominate. In some cases gastro- 
intestinal symptoms prevail, in others respiratory. But the cardinal 
manifestations of the affection are the continued fever of from one to 
three weeks' duration, with irregular remissions, palpable spleen, and 
the Plasmodium malarias in the blood. Bearing these clinical symp- 
toms in mind and those of the diseases suspected, there ought to be 
no difficulty in differentiating remittent fever from typhoid fever or 
protracted influenza — with both of which diseases it is most apt to 
be confounded. The quinine test is not reliable in the remittent form 
of malaria as the fever often resists medication. 

The prognosis of remittent fever is favorable, except for the ten- 
dency to recurrences at shorter or longer intervals and of ultimately 
becoming chronic. 



408 DISEASES OF CHILDREN 



Chronic Malarial Cachexia 



The diagnosis of this condition is often very difficult, since its prin- 
cipal symptoms — anemia, debility, enlarged spleen and liver — are 
also pathognomonic of severe rachitis, pseudoleukemia, and similar 
wasting diseases. Corroborative data may be obtained from a history 
of previous attacks of either intermittent or remittent fever or the 
occurrence of periodical headache, neuralgia, dysentery or hematuria. 
One should be very cautious, however, in making a hasty diagnosis 
of "malaria" unless there be ample reason for exclusion of the other 
affections and the therapeutic quinine test prove positive. 

Chronic malarial cachexia per se is not dangerous to life, but is apt 
to prove so from its concomitant symptoms, such as profound anemia 
and amyloid degeneration of the viscera. 

Treatment. — As malarial fever is ordinarily contracted through the 
bites of mosquitoes, to prevent malarial disease, we must either de- 
stroy the mosquitoes or avoid their bites. An effort should be made 
also to isolate, by mosquito netting, all cases of acute malarial disease, 
in order to deprive the mosquitoes of the infective material. Another 
very important measure is to prevent the breeding of mosquitoes. 
Mosquitoes lay their eggs in water barrels, pans, tin cans, pots, kettles, 
wells, springs, rain pools, cess pools, drainage taps, ponds — in short, 
wherever stagnant water is found. We have to see to it that all 
water receptacles are closely covered with thin wire gauze, and that 
where drainage cannot be carried out, the surface of ponds, etc., are 
covered with a film of kerosene oil. One ounce of oil to 15 square 
feet of water will usually suffice. The oil must be renewed about once 
a week during the mosquito season. A solution containing 1 pound 
of sulphate of copper and 1 pound of unslaked lime in 10 gallons 
of water will kill the mosquito larvae when added in proportion of 1 of 
the solution to 50 of the infected water. 

White people settling in malarial tropical regions should not plant 
their houses near native settlements. 

Where the aforementioned prophylactic measures cannot be prop- 
erly enforced, resort should be had to the routine administration of 
quinine during the mosquito season. Whether as a prophylactic or 
curative measure, quinine is the specific destructive agent of the 
malarial parasites. To obtain prompt results it should be given in full 
doses. Children tolerate relatively much larger quantities of quinine 
than adults. An infant of two years requires about 15 or 20 grains 
a day until the attack is controlled, and smaller doses after. For chil- 
dren unable to take quinine in capsules, I prefer the newer "tasteless" 



SPECIFIC COMMUNICABLE DISEASES 409 

quinine preparations, such as quinine ethyl carbonate, diquinine car- 
bonic ester, etc., or quinine tannate, or I administer the ordinary bit- 
ter quinine per rectum (10 grains of quinine subsulphate in 4 drams of 
water by means of colon tube). In cases of marked gastric irritability 
or in those very grave in nature or protracted in course, quinine may 
be employed in 5 grain doses hypodermically. For this purpose, bi- 
muriate of quinine and urea, the hydrochlorosulphate, the hydrobro- 
mate, or the bisulphate may be used. Ugly sloughing which is apt 
to follow at the site of the injection may be prevented by cleanliness 
of the needle and skin, and by throwing the solution deeply into the 
subcutaneous tissues and sealing the point of puncture with adhesive 
plaster. 

In protracted cases iron and arsenic (Fowler's solution) will be 
found useful additions to the quinine. When there is a great tendency 
to recurrences of the malaria, permanent residence in dry mountainous 
regions will sometimes remain the only curative measure at our com- 
mand. 

I> Quinine Ethyl Carbonate, or i 

Diquinine Carbonic Ester 3 ss 2.00 

Syr. simplicis I ii 60.00 

M. 
S. — One teaspoonful every two to four hours, for 
a child three years old. 

IJ Quininse Mur. 

Acetanilidi 
Podophyllini 
Ext. Nucis Vomicae 
M. ft. caps. no. xii. 
S. — Two capsules every three hours, for a child six 
years old. 

Yy, Acidi Arsenosi 

Quininse Mur. 

Ferri Sulph. Exs. 

Pulv. Ehei 

M. ft. caps. no. xx. 
S. — Two capsules every six hours, for a child ten 
years old (in chronic malaria). 

R Elixir Ferri Pyrophosphatis, Quininas 

et Strychnina? (N.F.) S i ss 45.0 

Syr. Aurantii q. s. 3 iii 90.0 

M. 
S- — One teaspoonful three times a day, for a child 
four years old (in convalescence). 



gr. xv 


1.00 


gr. vi 


0.40 


gr- % 


0.008 


gr. % 


0.016 



gr- Yio 


0.006 


3 ss 


2.00 


gr. x 


0.66 


gr. v 


33 



410 DISEASES OF CHIILDREN 

Treatment should not be discontinued, until the blood has become 
free from plasmodia or pigment and the spleen has assumed its normal 
size. 

Dengue 

(Breakbone Fever. Seven-Days-Fever) 

This specific affection is transmitted by bites of mosquitoes, the Culex 
fatigans and Stegomyia fasciata. While most common in the tropics, it 
is not rarely observed in Texas. It is characterized by two febrile 
paroxysms of about three days' duration with an intermission of a day 
or two. The drop of temperature is accompanied by profuse sweating. 
With the second rise of temperature a roseolar or scarlet-like eruption 
makes its appearance. The disease is associated with a marked leuco- 
penia, severe pain in the head (eyeballs), back and joints, and in young 
children, delirium and convulsions — the latter probably the result of 
hyperpyrexia (104° to 106° F.). The second or third attack is milder 
than the first one. The disease is benign in character and usually re- 
sponds promptly to the administration of salicylates and quinine. 

In a recent paper on dengue Ch. F. Craig* reaffirms his views on 
the similarity of dengue and yellow fever, both clinically and etiologi- 
cally and speaks strongly in favor of the spirochetal nature of dengue. 
Clinically, both diseases have a sudden onset, run a comparatively 
rapid course, and terminate by crisis rather than by lysis. 

In both diseases the cause is present in the blood, but only during 
certain periods; in both, the injection of unfiltered blood from patients 
suffering from the disease results positively, the incubation period in 
yellow fever being usually three and a half days, while in his experi- 
ments, the incubation period in dengue averaged three days, fourteen 
hours; in both, the injection of filtered blood produces the disease, 
thus proving that both are due to a filtrable virus ; in both, the transmit- 
ting agent is a mosquito ; and both, finally, have proved to be non- 
contagious. 

Rocky Mountain Fever 

(Tick Fever, Spotted Fever) 

This disease is endemic in the valleys of the Rocky Mountains in 
Idaho and Montana. It has also been found in the valleys of Nevada 
and Wyoming. It occurs in the spring months and while the cause of 
the affection is still unknown, it has been definitely established, espe- 
cially by Ricket and King that it is transmitted by infected ticks, the 
Dermacentor occidentalis. The disease is characterized by a continu- 



*Jour. Am. Med. Assn., Oct. 30, 1920. 



SPECIFIC COMMUNICABLE DISEASES 411 

ous moderate fever, which falls by lysis, severe chills, arthritic and 
muscular pain, and a profuse macular, or petechial rash, which appears 
(from the second to the fifth day) first upon the ankles, wrists and 
forehead but soon spreads over the entire body. In severe cases there 
may be delirium, tachycardia, out of proportion to the temperature, 
albuminuria and casts and jaundice. 

Treatment. — Protection against the bites of the ticks, particularly by 
protecting the hands and feet. The active treatment is symptomatic. 

Pestis Americana 

(Yellow Fever. The Yellow Jack) 

While the specific microbe of this acute infectious fever is still un- 
discovered,* it is definitely settled — thanks principally to the investi- 
gations of Ch. Finley, Reed, Carroll, Agramonte and Lazear — that 
yellow fever is spread by the bite of the Stegomyia calopus mosquito. 

Pathology. — The liver is the chief seat of the pathologic alterations. 
The liver cells swell and degenerate and by pressure upon the capillaries 
obstruct the flow of bile and thus give rise to the hepatogenous jaundice. 
The degenerative process proceeds also in the interlobular capillaries, 
interfering with the portal circulation and causing congestion of the 
gastrointestinal tract. On postmortem examination the stomach and 
intestines are often found to contain large quantities of blood. Puncti- 
form hemorrhages are observed also in the other organs of the body. 

Symptomatology. — After an incubation period of from 2 to 6 days, 
the attack usually sets in with vomiting, severe abdominal and spinal 
pain, high fever (about 104° F.) not rarely convulsions, and albuminuria 
(usually the second day). This attack may last from two to four days 
and is followed by a 24 hours ' remission accompanied by sweating, when 
the second paroxysm of fever develops with marked jaundice, hemor- 
rhage from the stomach (black vomit), slow pulse and general prostra- 
tion. This paroxysm in favorable cases usually lasts from two to three 
days ; the patient passes into a sound sleep and is then well on the road 
to convalescence. In unfavorable cases the temperature continues to 
rise, the hemorrhagic vomiting persists, and there develop in addition, 
clammy sweats, complete anuria, delirium, convulsions and coma. In 
the United States the mortality ranges between 20 and 25 per cent. 

Mild cases may be mistaken for dengue and malarial fever — in neither 
of these affections, however, do we find albuminuria and marked jaundice. 
Furthermore, malaria presents the Plasmodium in the blood. (See "Den- 
gue.") 



*Noguchi claims that it is a spirochete, the Leptospira icteroides. (Jour. Am. Med. Assn., 
Jan. 8, 1921.) 



412 DISEASES OF CHILDREN 

Treatment. — Destruction of mosquitoes at their source; screening of 
the patient, and fumigation of the sick room with sulphur or formalde- 
hyde. Prophylactic inoculation is recommended by Noguchi and Pazeja. 

The active treatment is symptomatic. With the claim of a spirochete 
being the cause of yellow fever, neosalvarsan would seem to me to be the 
remedy worth trying. Plenty of alkaline waters, warm baths, liquid 
diet, cardiac stimulants, and sedatives, if the pain is very severe. 

Ileocolitis Epidemica 

(Dysentery) 

This form of dysentery is entirely distinct from hemorrhagic enteritis 
or proctitis spoken of in connection with gastroenteritis on page 257. 
It is an infectious epidemic, and sometimes sporadic disease, caused by 
the dysentery bacilli described by Shiga, Kruse and Flexner. Amebic 
dysentery which is seen here sporadically is endemic in the tropics. The 
lesion is localized principally in the sigmoid flexure and rectum, or also 
in the entire colon up to the ileocecal valve or even the lower portion of 
the ileum, and varies from a simple inflammation of the mucosa to 
a croupous, diphtheritic inflammation, with a fibrinous exudate or a 
membranous deposit, ulcer formation, and necrosis (gangrene). Dysen- 
tery is most common during August and September and late in autumn. 
It most frequently affects young children who are on a mixed diet. 

In the majority of instances dysentery begins with simple diarrhea, 
without constitutional symptoms, and after from twenty-four to forty- 
eight hours is followed by the characteristic symptoms later to be spoken 
of. In some cases the onset is sudden with high fever and, in small 
children, with convulsions. Once the affection is established the symp- 
tomatology is quite pathognomonic : colic, tenesmus, and bloody stools. 
The colic precedes and accompanies defecation and is followed by severe 
and prolonged tenesmus. The bowel movements vary between ten and 
thirty or more in twenty-four hours, and the dejecta consist either of 
pure blood or of blood and dirty ragged shreds of tissue and fecal masses. 
The abdomen is most frequently sunken, permitting palpation of the 
contracted colon. The tongue is dry and heavily coated, the lips are 
cracked and covered with sordes, the appetite is lost, and the child 
suffers from intense thirst, and occasionally from nausea and vomiting. 
As a rule, the temperature is raised (intermittent), but it may be normal 
or subnormal. After a few days the patient becomes greatly emaciated 
and prostrated, very anemic, and the expression of the face denotes 
great suffering. Quite a number of children succumb during this stage 
of the disease (fulminating type) ; others again continue to battle for life 
and after a course of from seven to ten days begin to improve, the stools 



SPECIFIC COMMUNICABLE DISEASES 413 

becoming less bloody and more feculent in character, the anorexia less 
marked, and the general condition much better. Relapses are not rare, 
and when they occur, there is a great tendency toward the transition of 
the acnte into a chronic process, with a very tedious convalescence, or 
death from exhaustion. 

An attack of dysentery may be complicated by perforation peritonitis, 
abscess of the liver, fissura or prolapsus ani, pulmonary affections, noma, 
parotitis suppurativa, etc., and may be followed by intestinal cicatrices 
and stenosis, paralysis of the sphincters, paresis of the extremities, and 
marasmus. 

The very protracted cases of dysentery are usually found to be due to 
the ameba coli (entameba histolytica dysenterise). The differentiation 
between this form of dysentery, that due to Shiga 's bacillus, and catar- 
rhal enteritis is important from the therapeutic point of view and can 
readily be made by a bacteriologic and microscopic examination of the 
dejecta. Furthermore, it is well to remember that foreign bodies in the 
lower bowel may give rise to a group of symptoms similar to those of 
dysentery; and that an inflamed prolapsed rectum, intussusception, an 
ulcerated rectal growth or hemorrhoids with coincident enteritis are 
very apt to mislead in the diagnosis. Careful examination (inspection 
and palpation) of the rectum disposes of these difficulties. 

Treatment. — Similar to a patient with typhoid, patients suffering 
from dysentery need not be strictly isolated. The dejecta and every- 
thing coming in contact with them, however, should be thoroughly disin- 
fected. During an epidemic the drinking water, fruit and vegetables 
should be boiled, and all modes of exposure to infection (mosquitoes, 
flies!) avoided. 

Acute dysentery calls for perfect rest in bed, an opiate (preferably 
hypodermically or per rectum) for the relief of pain, and light as- 
tringent diet (tea and toast without sugar, rice and barley gruel with- 
out milk, and later albumin milk with equal parts of barley or rice 
water). In the beginning the bowels should be cleansed with a mod- 
erate dose of castor oil or syrupus rhei by mouth and one sterile cool 
water irrigation. The patient is then put on pulveris Doveri, % 
grain, for every year of the child's age every three hours, and if there 
is no vomiting also on the following mixture : 

I£ Bisrnuthi Subnitratis 3 iv 15.00 

Vini Ipecacuanhas 3 i 4.00 

Mist. Creates Comp. 3 iv 15.00 

Aq. Anisi q.s.ad f I iii 90.00 

M. 
S. — One tea spoonful every two to four hours, for a 
child three years old. 



414 DISEASES OF CHILDREN 

In severe cases the intestines should be irrigated once a day with 
1:1000 of nitrate of silver, and once a day with 1:1000 quinine sul- 
phate solution, the latter especially in amebic dysentery. The irri- 
gation should be executed very gently by means of a soft rubber catheter 
attached to an ordinary irrigator. Sometimes starch water (1 ounce to 
1 pint) with a few drops of tincture of opium will relieve the tenesmus. 
Hydropathic applications to the abdomen (plain Priessnitz compress, or 
warm turpentine stupes) are useful. 

Flexner* recommends polyvalent antidysenteric serum (10 to 20 c.c.) 
subcutaneously or intravenously. 

Collapse should be combated by local heat, cognac, red wine with a 
hot infusion of cinnamon, camphor, strychnine, etc. During convales- 
cence care in dieting is still demanded (recurrences are common), 
and the persistent anemia calls for iron, analeptics in the form of 
strengthening food (fresh eggs, milk with cereals, broths, etc.) and 
plenty of fresh air, and, whenever possible, a sojourn in the country, 
preferably at the seashore. 

In amebic dysentery quinine (2 to 5 grains t. i. d.) by mouth, and 
emetine hydrochlorate (% grain) hypodermically once a day are of great 
service. 

In chronic dysentery the tannates in conjunction with the quinine 
and silver irrigations do better than the bismuth preparations. Other- 
wise the management is the same as in acute dysentery. The more pro- 
tracted the course, the greater the exhaustion and loss of blood ;^and the 
younger the child, the worse the prognosis. The mortality in different 
epidemics varied between 5 per cent and 30 per cent. Early attention 
is a very great factor in reducing the mortality and the tendency toward 
chronicity. 

Rheumatismus Acutus 

(Rheumatic Fever, Polyarthritis Acuta) 
Acute inflammatory rheumatism is an infectious disease with a spe- 
cific predilection for the fibrous tissues and serous membranes. The 
muscular and neural structures, however, are not exempt from it. 
The discovery of the rheumatism-producing microorganism is a mat- 
ter probably of the very near future. In fact it is quite probable that 
the so-called streptococcus or diplococcus rheumaticus which is fre- 
quently found in the exudate of the joints and in the blood plays a 
very important role in the causation of rheumatic fever. 

Rheumatism is most common in children over five years of age, but 
no age (even infants under one year) is exempt. A hereditary dis- 
position can usually be traced in the majority ol cases. 



*Jour. Am. Med. Assn., lxxvi, No. 2, 1921. 



SPECIFIC COMMUNICABLE DISEASES 415 

Similar to other infectious diseases, rheumatic fever is most prev- 
alent in certain climates and seasons of the year. It presents a pro- 
dromic stage of variable duration, which is characterized by chilli- 
ness, languor, etc. Like the eruptive fevers it is manifested by gen- 
eral febrile disturbance with local lesions. To a certain extent it is 
self-limited, since with exhaustion of the fertile soil in one place, the 
inflammation "jumps" to another place. It ordinarily yields promptly 
to specific medication ; in this respect also resembling infectious fevers, 
e. g., malarial fever. 

After a brief prodromic stage, the symptoms of acute rheumatism 
usually set in suddenly, with chills, rise of temperature, vomiting, 
and vague pain in several parts of the body. In very young children 
the onset is not rarely associated with cerebral symptoms, especially 
convulsions. Older children often complain of sore throat (lacunar 
tonsillitis), and in some cases articular swelling forms the first prin- 
cipal manifestation of the affection. The disease, once established, 
differs in its symptomatology and course but little from that observed 
in rheumatism in adults, except, as will be seen later, that in children 
there is a greater tendency toward cardiac complications, while the 
articular involvement is usually less pronounced. 

The joints of the knee, ankle, elbow and wrist are most commonly 
affected, occasionally also those of the phalanges and hip. In one case 
under observation the lower dorsal vertebras were so severely affected 
as to greatly resemble acute spondylitis. The articular involvement 
is accompanied by stiffness, slight redness, swelling and excruciating 
pain, the latter especially on attempting to walk, or moving or hand- 
ling the parts affected. The inflammation may abruptly cease at one 
or more joints and, as suddenly, attack others. During the acute 
stage the temperature varies between 102° and 104° F., and as the 
inflammation "jumps" from joint to joint there is usually a sharp 
rise of temperature. Correspondingly, the temperature falls with 
abatement of the local manifestations. The urine is usually scanty 
and high-colored, filled with urates, and occasionally contains traces 
of albumin. The characteristic sour (lactic acid) sweats observed in 
adults are much less pronounced in children. 

There is no definite limitation to the duration and course of the 
affection. Mild cases, after pursuing a mild febrile course for a few 
days, may either recover entirely or enter into a subacute, afebrile 
stage, which for weeks and months may be manifested by vague ar- 
ticular and muscular pain, and ultimately end either in complete re- 
covery, or leave behind some form of subacute or chronic heart dis- 



416 DISEASES OF CHILDREN 

ease. Indeed, it is usually in such cases that the heart affection is 
overlooked, and unexpectedly discovered some time (years!) later, with- 
out being able to disclose a rheumatic history. Severe cases may 
run a febrile course of from three to five weeks and sometimes as many 
months, if left untreated. It is well to remember that the gravity 
of an attack is not always commensurate with the severity of the 
articular involvement. In quite a number of cases, endocarditis or 
pericarditis, or both, may predominate while the other symptoms 
are barely noticeable. Hence the importance of a routine and care- 
ful examination of the heart of children suffering from rheumatic 
and "growing" pain, or chorea. The latter disease, by the way, is 
closely allied to, and may precede, accompany or follow rheumatism 
in its various forms. (See "Chorea".) 

The earliest symptoms of rheumatic endocarditis are increase of 
frequency and intensity of the heart beat and precordial pain. This 
is soon followed by the usual physical signs of endocarditis — those 
of mitral regurgitation predominating. Endocarditis forms the most 
frequent (in about 60 per cent) complication of inflammatory rheu- 
matism and usually sets in within the first ten days from the onset. 

Pericarditis is observed only in about 10 per cent of the cases, and 
somewhat later than endocarditis. It is manifested by a dry friction 
sound, heard at the apex or base of the heart, or by a serous exuda- 
tion which may rapidly, and unnoticeably, disappear, or persist and 
lead to pericardial adhesions and their accompanying more"" or less 
grave sequelae. 

Less frequent complications are pleuritis and pneumonitis. Both 
these affections are ordinarily limited to the left side. The pleuritic 
effusion may be serous or serofibrinous and is most frequently asso- 
ciated with pericarditis. Of still less frequent occurrence are perito- 
nitis and nephritis. The abdominal pain, however, not infrequently 
complained of by children during an attack of rheumatism, is usually 
due to muscular hyperesthesia and not to peritoneal involvement. 

As in adults, rheumatism of children may also affect the muscles. 
Eheumatic torticollis is especially common, and in severe cases is 
apt to be mistaken for cervical spondylitis. Muscular rheumatism 
affecting the muscles of the lumbar region may resemble lumbar spon- 
dylitis; and that of the leg may give rise to symptoms (pain on motion, 
lameness, stiffness, etc.) simulating coxitis, or poliomyelitis. As pre- 
viously mentioned, rheumatism of the abdominal muscles may simulate 
peritonitis, while rheumatism of the intercostal muscles may be mis- 
taken for dry pleurisy. In all these cases a diagnosis can usually be 



SPECIFIC COMMUNICABLE DISEASES 



417 



arrived at by bearing in mind the pathognomonic symptoms of the 
affections the muscular rheumatism resembles, and the fact that the 
latter promptly yields to the salicylates, and that as a rule, there is a 
history of involvement of other groups of muscles. 

Eheumatism may also affect the periosteum and give rise to thick- 
ening of the underlying bone which condition with the accompanying 
pain and fever, may simulate incipient osteomyelitis. From what has 




Fig. 93. — Rheumatic torticollis of several weeks' duration in a child six years old 
which greatly resembled cervical spondylitis. 

been said, it can readily be seen that the diagnosis of rheumatism in 
its various phases is far from being easy. 

Moreover, articular rheumatism may also be mistaken for syphilitic, 
gonorrheal, tuberculous, and the so-called septic arthritides, scurvy 
and its allied affections. 

In our endeavor to differentiate rheumatism from the divers forms 
of articular and periarticular inflammations, we must bear in mind 



418 DISEASES OF CHILDREN 

that rheumatism is a primary febrile affection, as a rule, sudden in 
development; that its inflammatory process is transient, and its local- 
ization multifarious and rapidly shifting, and, finally, that its course 
is promptly and often permanently influenced by the salicylates. 

Differential Diagnosis 

Epiphysitis Syphilitica. — Syphilitic epiphysitis develops slowly, in 
the first few months of life — rather exceptional for rheumatism — in as- 
sociation with other symptoms of congenital syphilis. It runs an 
afebrile course and yields promptly to antisyphilitic medication. 

Arthritis Heredo syphilitica (Tarda). — Hereditary syphilitic arthritis 
develops gradually, and affects principally one or both knees. It is 
usually associated with other syphilitic symptoms, especially intersti- 
tial keratitis. As a rule, the subjective disturbances are incongruous 
with the severity and extent of the local signs, and the arthritis is 
but rarely accompanied by inflammatory symptoms. It yields promptly 
to antisyphilitic medication. Puncture of the swelling reveals sero- 
fibrinous fluid and not rarely the spirochete. 

Arthritis Gonorrheica. — Gonorrheal arthritis occurs as a complica- 
tion of gonorrheal ophthalmia, urethritis, or vulvovaginitis. It is most 
frequently limited to one knee, more rarely to both knees, or to the 
maxillary or sternal articulations, and is accompanied by pronounced 
inflammatory local and general symptoms. The articular involvement 
is more lasting than that of acute rheumatism, and resists antirheu- 
matic measures. 

Arthritis Tuberculosa. — Tuberculous arthritis develops gradually, 
usually remains limited to one joint, and resists antirheumatic treat- 
ment. Atrophy of the affected limb sets in early, and an x-ray ex- 
amination often shows involvement of the bone. The tuberculin reaction 
is often positive. 

Arthritis Septica. — Septic or infective arthritis is usually monoarticu- 
lar and arises secondarily to sepsis (e. g., purulent arthritis in sepsis 
neonatorum) or to acute infectious diseases, such as typhoid fever, in- 
fluenza, pneumonia, diphtheria, scarlatina, etc. In two cases under our 
observation purulent arthritis of the knee followed tonsillectomy. The 
history is the most reliable clue in the diagnosis, and the finding of the 
streptococcus, pneumococcus, etc., in the seropurulent fluid obtained 
by exploratory puncture of the swelling is decisive. 

Scorbutus (Barlow's disease) purpura hemorrhagica aud hemophilia 
(with sanguineous effusion into the joints) also may be mistaken for 
acute articular rheumatism. In the hemorrhagic diseases, however, 
there are hemorrhages from and into other parts of the body. The 



SPECIFIC COMMUNICABLE DISEASES 419 

articular swelling is not as evanescent. Fever is usually absent or 
slight. Furthermore, Barlow's disease is observed in very young in- 
fants, who are rarely attacked by rheumatism, and yields promptly to 
antiscorbutic diet. Antirheumatic treatment is futile. 

Osteomyelitis. — The swelling does not appear until a few days after 
the onset of the disease, and has its center, not opposite the joint, as in 
articular rheumatism, but above or below, opposite one or other of the 
epiphyses of the bones entering into the formation of the joint. In 
advanced cases the swelling extends along the shaft to a variable 
distance. In contrast to osteomyelitis rheumatism is rarely limited 
to a single joint, and its swelling never suppurates. Leucocytosis is 
absent in rheumatism, and, as a rule, marked in osteomyelitis. A 
skiagraph is helpful in the differential diagnosis. 

Prognosis. — Rheumatic fever per se is very rarely fatal, but only very 
few patients emerge uninjured from a severe attack of rheumatism. In 
probably two-thirds of the cases some form of heart disease is acquired, 
which sooner or later manifests evidence of its destructive character. 
This obtains particularly in recurrent rheumatism, as w T ell as in cases 
improperly cared for, as regards rest and specific medication. 

Treatment. — Rest in bed is the most important therapeutic measure 
in the prevention of grave complications and sequelae, and should be 
enjoined at least during the febrile course of the disease. Medicinally, 
the salicylates act specifically in all acute rheumatic conditions, and 
their administrations should be continued until every vestige of the 
disease has disappeared. In the beginning, the salicylates should be 
pushed to their full tolerance — let us say 1 grain of the sodium salicy- 
late for every year of the child's age, every two hours, until the acute 
symptoms have been arrested, then every three or six hours according 
to indications. The salicylates may be alternated with sodium bi- 
carbonate until the urine becomes alkaline, or with atophan. With the 
appearance of cardiac complications, the iodides, in small doses, should 
be added, and if necessary, also digitalis. For the relief of articular pain 
and swelling, the joint should be enveloped in absorbent cotton wrung 
out of a saturated solution of bicarbonate of soda. The compress should 
be covered with oiled silk and a flannel bandage and changed every 
two to four hours. When the pain is very acute I have found the 
following very serviceable: 

1$ Olei Gaultheriae 
Guaiacolis 

Ichthyolis aa 3 ss 2.00 

Adipis Lanse §i 30.00 

S. — Apply gently twice a day, and 
cover with a flannel bandage. 



420 DISEASES OF CHILDREN 

Acute rheumatism being an infectious disease, I have no faith in 
"mathematical dietetics" as a cure of the disease; hence, do not 
employ any specific dietary, but limit the diet to a so-called "fever 
diet" during the febrile stage of the disease and to easily digestible 
food of all sorts later. This has the advantage of maintaining the nu- 
trition of the patient who at best is weak and anemic. On the other 
hand, in a number of refractory cases the diet has to be limited, and 
I have found that a purely vegetable and cereal diet (without milk 
or sugar, but made palatable by the addition of sweet butter) will 
often be very beneficial. The prolonged use of the iodides and cod 
liver oil is always in order in the convalescent stage, and a sojourn 
in a dry and high inland resort will prevent recurrence and chronicity. 

$ Natrii Salicyl 3 ii 8.00 

Mist. Rhei et Sodas 3 iii 12.00 

A q. Destil. q. s. ad f I iii 90.00 

M. 

S. — One teaspoonful every two to four hours, for 

a child four years old. 

I£ Antipyrinse 3 ss 2.00 

Natrii Salicyl. 3 iss 6.00 

Caffeinae Natrii Benzoatis gr. xvi 1.00 

Syr. Simplicis 3 iv 15.00 

Aq. Destil. q. s. ad f I ii 60.00 
M. 

S. — One teaspoonful every six to twelve hours, 

for a child four years old (for quick relief of pain.) 

fy Olei gaultherias 3 i 4.00 

Ft. caps. no. xii. 
S. — One capsule every four to six hours, for a 
child six years old (for subacute rheumatism). 

The throat should be kept disinfected by Dobell's or similar anti- 
septics. Constipation should be remedied by cascara sagrada. 

Recurrent rheumatism often calls for complete enucleation of the 
tonsils, and careful attention to the teeth. 

Rheumatoid Arthritis 

(Rheumatismus Chronicus, Arthritis Deformans) 

Chronic rheumatism in children is very rare. Similar to what oc- 
curs in adults, it may supervene after recurrent attacks of acute or 
subacute rheumatism, or, very exceptionally, it may develop primarily. 
In either case the local manifestations are clinically alike, and consist 



SPECIFIC COMMUNICABLE DISEASES 421 

of gradual enlargement of the affected joints, with atrophy of the 
muscles around the joints, painful and hindered motility, ankylosis, 
and deformity of the bones at the articulations. It is usually bilateral. 
The course of this form of rheumatism though very protracted, and 
extending over a period of years, is usually not as slow as in adults. 
It eventually leads to crippling of the patients, and fatal termination 
either from exhaustion or complicating tuberculosis. 

Chronic articular rheumatism may be confounded principally with 
syphilitic and tuberculous affections of the joints. Syphilitic arthritis 
is usually accompanied by other syphilitic symptoms, especially kera- 
titis, and ordinarily yields to antisyphilitic treatment. The differen- 
tiation between simple chronic arthritis and tuberculous joints is 
quite difficult, since, as previously mentioned, the latter may follow 
the former. However, the absence of temperature and failure to ob- 
tain a positive tuberculin reaction, speak in favor of chronic non- 
tuberculous arthritis. The finding of a tuberculous exudation in the 
affected joint, of course, is decisive in the diagnosis. 

As the prognosis in protracted cases is very bad, active treatment 
should be begun early and not too rapidly discontinued, in disgust, 
because of more or less persistent failure to effect a cure. The salicy- 
lates with small doses of sodium iodide internally and 50 per cent ichthyol 
ointment externally should be given a thorough trial. Where stiffness 
and swelling of the joints prevail, daily gentle massage preceded by a hot 
local bath and followed by hot moist compresses often works wonders. 
Passive motion should be practiced early, and where the contractures 
are very pronounced one should not hesitate to reduce the same under 
primary anesthesia and proceed with the treatment just outlined. 
Concomitant acute symptoms should be treated in the same manner 
as in acute rheumatism, and when there is reason to believe that the 
diseased condition is the result of faulty metabolism (intestinal in- 
toxication or uric acid diathesis), the dietary should be regulated ac- 
cordingly (exclusion of meats, acids, liquors, etc.). Hypertrophied 
tonsils should be promptly enucleated, and decayed teeth, which can- 
not be filled, removed. 

I£ Natrii Iodidi 

Ext. Hyosciami Fl. 

Natrii Salicyl 

Syr. Sarsaparillse Comp. 

Aq. Destil. 

M. 
S. — One teaspocmful every four hours, for a child 
four years old. 



gr. xv 


1.00 


m. vi 


0.40 


3i 


4.00 


Si 


30.00 


. s. ad f 5 iii 


90.00 



422 DISEASES OF CHILDREN 

Still's Disease 

This affection generally sets in during the first three or four years 
of life and attacks girls more frequently than boys. It is characterized 
by gradually developing stiffness and enlargement of several joints, 
beginning with the knee, wrists and cervical vertebrae, and gradually 
extending to the fingers and toes. It differs pathologically from 
rheumatoid arthritis or tuberculosis in that it is free from destructive 
or proliferating processes of the bony structures. As may be readily 
determined by the roentgen ray examination, the enlargement of the 
joints is due purely to thickening of the soft tissues. Aside from the 
articular involvement, Still's disease is characterized by a more or 
less marked enlargement of the lymphatic glands (axillary, cervical 
and mesenteric) and of the liver and spleen. It is occasionally asso- 
ciated with a slight rise of temperature, and shows a tendency to 
pericardial and pleural affections. 

It is a very chronic, incurable affection of unknown etiology. Its 
progress may be partially arrested by the therapeutic measures out- 
lined under "Chronic Eheumatism". 

Rheumatismus Nodosus Infantilis, Erythema Nodosum, Peliosis Rheu- 
matica (Purpura Rheumatica) 

These three distinct diseased conditions are grouped together to 
facilitate their identification. They have several symptoms in com- 
mon, and bear a close resemblance to rheumatism. Their true nature, 
however, is a matter of conjecture, and with our present ignorance 
as to the identity of the specific rheumatic germ, there are no means 
of corroboration or of contradiction of any of the numerous assump- 
tions advanced by different authorities. 

Rheumatismus Nodosus Infantilis 

This disease is peculiar to early childhood and occasionally follows 
a protracted or recurrent attack of rheumatism, especially in asso- 
ciation with grave cardiac manifestations. It is characterized by 
the (often symmetrical) appearance, chiefly about the joints and the 
tendon insertions, of several nodules (noduli or osteomata rheumatic!) 
which grow to a perceptible size, and then either undergo regressive, 
fatty metamorphosis and absorption, or persist, become calcified and 
acquire a bony consistence. The nodules (exotoses) vary in size 
from a small pea to a plum and in number from one to a hundred. 
They are at first soft, flat and painful or tender to the touch, and later 
they become harder and rounder, resembling the fibromatous and osteo- 



SPECIFIC COMMUNICABLE DISEASES 



423 




Fig. 94 





Fig. 95 Fig. 96 

Still's Disease in a boy five years old. (G. E. Pisek.) 

Fig. 94. — Showing the arthritis being multiple. 

Fig. 95. — Periarticular changes in the left wrist joint. 

Fig. 96. — Symmetrical changes in the periarticular soft parts of the knees and 



ankles. 



424 DISEASES OF CHILDREN 

matous growths observed in "Myositis Ossificans" and in "Multiple 
Exostoses" (q.v.). 

Treatment. — Antirheumatic. 

Erythema Nodosum 

Until recently this affection has been looked upon as a skin dis- 
ease pure and simple. The sudden appearance, the rise of temperature, 
the self-limited course, and its association with more or less marked 
constitutional symptoms and occasionally grave complications (prin- 
cipally rheumatic pain, bleeding from mucous membranes and heart 
trouble), stamp it, however, as an acute infectious disease of obscure 
etiology. Locally, it is characterized by the appearance, chiefly on 
the anterior portion of the lower legs and forearms, of from a pea- to a 
walnut-sized, pale red, painful nodules which at first resemble con- 
tusions (erythema contusiforme). They gradually disappear, changing 
in color to bluish, green and yellow within from two to three weeks, 
as a rule, without any specific medication. 

Treatment. — Complications of the heart and joints demand anti- 
rheumatic treatment. 

Peliosis (Purpura) Rheumatica 

(Schonlein's Disease) 

The local manifestations of this affection consist of variously sized 
bright- to bluish-red hemorrhagic spots which are uninfluenced by 
pressure with the finger. Here and there they present a central 
papular hardness. The eruption is usually limited to the lower ex- 
tremities, especially about the knees and ankles, but the upper ex- 
tremities may be affected as well. The appearance of the eruption is 
preceded and accompanied by urticaria, articular pain and swelling, 
occasionally soreness of the soles of the feet, and difficulty in walking. 
Fever and constitutional symptoms are ordinarily slight. Occasionally 
we find edema of the face^ slight intestinal hemorrhage and enlarge- 
ment of the spleen. The hemorrhagic spots usually disappear in from 
ten to fourteen days. 

The prognosis is usually favorable, but the disease manifests a 
tendency to recurrences, and to cardiac complications. 

Treatment. — Symptomatic: salicylates; daily intestinal irrigation 
with a warm bicarbonate of soda solution (one ounce to 1 quart of 
water) ; rest in bed. Light diet. 



SPECIFIC COMMUNICABLE DISEASES 425 

Myositis 

(Inflammation of the Muscles) 

The causes of myositis are very numerous. "We had occasion to 
refer to scarlatinal and rheumatic myositis. It may also be trau- 
matic, gonorrheal, syphilitic and tuberculous in nature, and is occa- 
sionally observed in connection with other infectious disease, e. g., 
typhoid. Myositis is characterized by pain, swelling and loss of 
function of the affected muscles, and, in protracted cases, by con- 
tractures. Where pain predominates and the swelling is slight, myo- 
sitis may readily lead to diagnostic errors, as emphasized in the discus- 
sion of " Muscular Rheumatism." (See p. 416.) Traumatic, syphilitic 
and tuberculous myositides are prone to lead to suppuration, while 
simple so-called rheumatic myositis eventually subsides either spon- 
taneously or under antirheumatic treatment. 

Polymyositis 

This form of general myositis is of much graver nature than the afore- 
mentioned varieties. It occurs either primarily, without any apparent 
cause, or secondarily as a result of parasitic infection, such as trichinae, 
echinococci, cysticerci, etc. 

Preceded by prodromata of a few days' duration, consisting of head- 
ache, muscular pain, anorexia, and slight fever, the condition rapidly 
grows worse; the temperature rises, and edema of the eyelids and face 
appears which soon spreads over the entire body. Beginning also with 
the face, the entire musculature of the body (least marked in the hands 
and feet) rapidly becomes stiff, board-like, and very painful, so much 
so that the different functions of the body (mastication, deglutition, 
respiration, etc.) are interfered with and the condition greatly re- 
sembles that of cerebral rigidity. 

In some cases cutaneous edema predominates (dermatomyositis) , in 
others a hemorrhagic condition of the skin and mucous membrane (poly- 
myositis hemorrhagica). Some cases develop very slowly and lead to 
overgrowth of the connective tissue (myositis fibrosa). In trichiniasis 
the polymyositis is usually preceded by gastrointestinal disturbance, and 
the stools and the muscles reveal trichina? spiralis. The blood shows 
marked eosinophilia. 

In children the course of the disease is usually milder than in adults 
and, as a rule, ends in recovery. 

Treatment. — Symptomatic : thorough cleansing of the alimentary 



426 DISEASES OF CHILDREN 

tract; relief of pain by antispasmodics, and, in trichiniasis, large doses 
(tablespoonful every 3 or 4 hours) of glycerine. 

Myositis Ossificans 

Myositis ossificans multiplex progressiva is a disease of childhood, 
the majority of the cases on record having been observed in children 
under ten years of age. Anatomically, it is characterized by pro- 
gressive interstitial connective-tissue proliferation, with consecutive 
ossification. The affection begins with the muscles of the neck and 
back, then spreads to those of the extremities, and, finally, involves 
the masseter and temporal muscles. 

The etiology of the disease is unknown. 

The onset is sudden with fever, and a soft, painful swelling of a 
section of a muscle, over which the skin appears reddened and edema- 
tous. 

The febrile symptoms soon abate, but the swelling in the muscle 
persists, and gradually — it sometimes takes years — assumes a bony 
consistence. Several muscles may thus become affected, leading to 
disturbance of motion, rigidity and deformities, and ossification of 
a large portion of the body so that the patient becomes bedridden 
for life. The prognosis, therefore, is grave, and life is endangered 
early if the muscles of mastication and respiration are involved. 

Treatment. — Avoidance of traumatism; the salicylates andthe io- 
dides internally and externally; gentle massage and hot baths. 

Multiple Exostoses 

Bone tumors in children may be congenital or acquired. The latter 
variety has been spoken of in connection with rheumatism. (See p. 
422.) Congenital exostosis may escape observation for several years 
and then erroneously be attributed to acquired causes. The etiology 
of congenital exostosis is obscure. Some cases are traceable to syph- 
ilis hereditaria. Some authors are inclined to attribute it to a disorder 
of growth. Bone tumors localized in the immediate neighborhood of 
joints and interfering with motility should be extirpated. Underbill 
(Jour. Exp. Med., July, 1920) among others suggests that in the early 
stages of cartilaginous exostosis, during the proliferative cartilage 
changes, the progress of the disease may possibly be checked by proper 
dietary procedures, and especially by restriction of calcium and magne- 
sium intake. 



SPECIFIC COMMUNICABLE DISEASES 



427 




Fig. 97. — 'Multiple exostoses. The tumors, varying in size from a pea to a walnut, 
were especially numerous at the eostosternal articulations, the wrist-, knee- and 
ankle-joints. 

Meningitis Cerebrospinalis, see p. 605. 

Poliomyelitis Anterior, see p. 627. 

Encephalitis Lethargiea, see p. 624. 

Parotitis Epidemica 

(Mumps) 

Primary, idiopathic, epidemic parotitis is a contagious and infec- 
tious affection of the glandular substance (acini and the ducts) and 
the interstitial tissue of one or both parotid glands. It most fre- 
quently attacks children of from two to twelve years of age, more 
rarely younger and older children. One attack usually confers im- 
munity for life. 

Secondary or metastatic parotitis is not rarely met as a complica- 
tion or sequel of divers infectious diseases and has nothing in com- 



428 



DISEASES OF CHILDREN 



mon with epidemic parotitis. Infection occurs through the mouth or 
throat. The specific microorganism is still unknown. 

After an incubation period of from ten to twenty days and a pro- 
dromic stage of about forty-eight hours' duration (marked by gen- 
eral malaise, pain in the region of the ear and throat), typical epi- 
demic parotitis is characterized by a gradually increasing swelling 
of the parotid gland in front and below the ear and along the angle 
of the lower jaw. The swelling increases up to the third or fourth 
day, remains stationary for another two or three days, and then 
rapidly subsides. Quite frequently after subsiding in one parotid the 




Fig. 98. — Epidemic mumps. 

inflammation passes on to the other ; more rarely both parotids are in- 
volved simultaneously. The overlying skin is usually colorless; more 
rarely, pale red, glistening and painful. Exceptionally the glands 
undergo suppuration (probably due to mixed infection!) or chronic in- 
duration. The inflammation may extend to the other salivary glands, or 
to the lymphatic and lacrimal glands, involving the tonsils, lids, con- 
junctiva, and less frequently the testicles, or ovaries, vulva or 
breast — usually on the same side as the affected parotid. Occasion- 
ally the submaxillary glands alone are involved, and, where the par- 
otitis is bilateral and severe, there may be a confluence of the bilat- 
eral tumors. 



SPECIFIC COMMUNICABLE DISEASES 429 

Except pain in swallowing, in opening the mouth, chewing, turn- 
ing the head, etc., headache, occasionally vomiting, and a rise of 
temperature during the first or second day of the disease, the patient 
usually suffers no discomfort. Of course, the symptoms are materially 
changed if the testicles (orchitis parotidea) or ovaries, etc., are in- 
volved, or if complications make their appearance — rather rarely 
to be observed in cases of ordinary severity. Otitis and nephritis form 
the most frequent complications. They may occur during conva- 
lescence, less often during the acme of the disease. The nephritis is 
usually hemorrhagic, but benign, in nature. The otitis not rarely 
leads to temporary deafness. Other complications of parotitis on 
record are: meningitis, encephalitis, divers paralyses, psychoses, peri- 
carditis, endocarditis, arthritis, etc. — the same as are apt to be met 
in many other acute contagious and infectious diseases. Notwith- 
standing the possibility of grave complications and sequelae, the prog- 
nosis of parotitis is almost always favorable, rarely calling for any 
elaborate therapeutic measures. 

Treatment. — A few days' rest in bed, fluid diet, the salicylates for 
the relief of pain, and local application of lead or potassium iodide 
ointment with or without 10 per cent of ichthyol, or oil of hyoscya- 
mus, covered with absorbent cotton, usually suffice to effect a cure 
in the majority of uncomplicated cases. Complications should be 
treated according to indications. Surgery should not be resorted to 
unless there be definite signs of suppuration. It is advisable to iso- 
late the patient for about three weeks. 

Parotitis may be mistaken for swellings in the same region result- 
ing from stomatitis, alveolar periostitis, retropharyngeal abscess, and 
infected glands from other causes. Bearing in mind the cause, con- 
sistency and location of the tumor, the presence or absence of an 
epidemic, and the course and duration of the disease, there ought not 
to be any great difficulty in arriving at a correct diagnosis. 

The course of secondary parotitis differs with its cause. 

Pertussis 

(Tussis Coxvulsiva, Whooping-cough) 

Whooping-cough is a highly communicable epidemic and sporadic 
affection, during its height characterized by sudden more or less fre- 
quent paroxysms of coughing which are from time to time interrupted 
by deep, stridulous inspiration and followed by a period of apparent 
euphoria of variable duration. The specific germ of the disease is 
still unknown, although there seems ample reason for the belief that 



430 DISEASES OF CHILDREN 

the bacillus described by Jochmann, Krause, Borclet and Gengou is the 
immediate cause of the disease. 

As a rule, the course of pertussis is divisible in three distinct stages : 
stadium catarrhale, convulsivum and decrementi. 

The stadium catarrhale, which lasts about ten days, begins after an 
incubation period of from five to nineteen days. It is sometimes pre- 
ceded by a few indefinite prodromata, consisting of loss of appetite, 
languor, restless sleep, and slight fever; and as these symptoms grad- 
ually disappear they become replaced by those of a simple catarrh of 
the upper air passages, so that the advent of the grip or measles is 
often suspected. At first the cough is short, hacking, sometimes 
croupy in character, but it steadily grows worse, although returning 
at longer intervals. It is especially troublesome at night, and what, 
as a rule is particularly characteristic of the whooping-cough, the 
cough fails to respond to the remedies usually efficient in ordinary 
"coughs and colds." Toward the end of the catarrhal stage the 
child is off and on attacked by a paroxysmal loose cough, thus indicating 
the early advent of the second, convulsive stage, of the affection. 

The stadium convulsivum may last from two to four weeks or, if let 
run at random, as many months. The cough is violent and explosive, 
each paroxysm being often preceded by a slight aura, by vomiting, 
sneezing, etc., so that older children are usually aware of its approach. 

Children able to walk usually run towards a person or object to 
support themselves during the attack, and infants manifest the ap- 
proach of the paroxysm by a sudden outburst of crying. Each par- 
oxysm which lasts from one-half to five minutes consists of a number 
of short, barking, expiratory acts of coughing, from time to time 
interrupted by deep whistling or stridulous inspirations — which con- 
stitute the "crow" or "whoop" — and is ordinarily (sometimes fol- 
fowed by a second or third fit of coughing) concluded with the ex- 
pulsion of a glassy, tenacious mucus and often also vomiting of food 
residue. During a paroxysm the face is at first red, then cyanosed and 
the veins in the neck swell. As the attacks grow worse, there is 
considerable venous stasis, puffiness of the face (which remains oc- 
casionally permanent) especially at the eyelids; there may be bleed- 
ing from the nose and throat, in the skin, conjunctiva, more rarely 
from the ear (rupture of the drum membrane, which heals sponta- 
neously), in the meninges, etc. In delicate and younger children a 
paroxysm is not rarely associated with involuntary defecation and 
urination, and at times also with general convulsions. The number of 
paroxysms varies between ten and sixty in twenty-four hours. They 



SPECIFIC COMMUNICABLE DISEASES 431 

are more frequent when the patient lives in unhygienic surroundings, 
after overloading the stomach, on excitement from any cause (cry- 
ing, laughing, etc.), irritation of the nasopharynx and larynx, etc. 
(often a useful means of diagnosis!). In mild and moderately severe 
cases the child is apparently quite well between the attacks; in very 
severe cases, however, the patient is weak, pale, emaciated and suffer- 
ing from troublesome bronchitis and often from a number of the other 
grave complications soon to be related. Under proper treatment the 
paroxysms in uncomplicated cases are, as a rule, more or less checked 
after from ten to twenty days. The paroxysmal stage is then followed 
by the regressive stage, stadium decrement!. The attacks become less 
frequent, they lose their typical character, the cough returns to the 
original catarrhal type and finally abates entirely. This declining 
stage ordinarily lasts from two to three weeks. Occasionally, how- 
ever, especially in cases exposed to unsanitary conditions and careless 
treatment, this stage may continue for months and be interrupted by 
relapses which often undermine the patient's constitution and lead 
to irreparable lesions in different organs of the body. 

Divers complications and sequelae have been noted: Of the lungs: 
capillary bronchitis, bronchopneumonia, emphysema, and bronchiec- 
tasis, phthisis and acute miliary tuberculosis (as a result of caseation 
of the bronchial glands) ; of the heart: dilatation, pericarditis, and myo- 
carditis; of the Drain: divers paralyses (hemiplegia, facial, laryngeal, 
etc.), hemorrhagic or tuberculous meningitis, encephalitis, softening of 
the brain, mental affections, such as imbecility, idiocy and different 
forms of insanity; of the spinal cord: myelitis, hemorrhagic inflamma- 
tions, and polyneuritis; of the ears: otitis, with or without permanent 
deafness; of the eyes: amblyopia, amaurosis; also nephritis, sublingual 
ulceration (as a result of friction of the sublingual tissues against the 
teeth during a paroxysm) severe epistaxis, and emphysema cutis (pneu- 
mohypoderma, q. v.) from rupture of some pulmonary alveoli. Delicate, 
especially bottle-fed babies, not rarely suffer from gastroenteritis with 
subsequent marasmus. Finally, sudden collapse from respiratory and 
heart failure may ensue at the acme of a protracted fit of coughing. 

Fortunately, the cases are not all of so grave a nature and so dread- 
ful in their consequences. Numerous abortive cases are on record in 
which the second stage is devoid of the " whoop" (sometimes re- 
placed by attacks of sneezing), and the third is of very brief duration, 
so that in the absence of an epidemic or a definite source of infection 
there is justification for a doubtful diagnosis. When the whoop is 
absent, some assistance in the diagnosis may be obtained by a careful 



432 DISEASES OF CHILDREN 

examination of the blood, which will show that during the second 
stage the polynuclear cells are increased twice in number, and the 
lymphocytes about four times. Of diagnostic importance is also the 
fact that the urine has a high specific gravity (1,022-32) and con- 
tains an excessive amount of uric acid crystals. The diagnosis is often 
almost impossible during the first stage of the affection especially if 
following measles, which is quite frequently the case, and time alone 
is the only reliable guide. 

No other communicable affection of childhood is so lightly regarded 
by the laity and so carelessly treated by the physician as that under 
discussion. Notwithstanding the fact that it prevails during the 
greater part of the year ; that its mortality ranges between 4 per cent 
to 6 per cent as an immediate result of the disease, and at least as 
high as 10 per cent in consequence of complications and sequelae,* 
no strenuous effort is being made to still its ravages, to arrest its 
spread or to abort its course. The fallacious impression has gained 
firm ground that whooping-cough "must run its course of from six 
to eighteen weeks," and even the scientific, practical physician wisely 
nods his head in affirmation and despair, lest he be ridiculed by the 
therapeutic nihilist. One has to be bold to venture to claim success 
in allaying the spasm, reducing the number of paroxysms, and pre- 
venting the dreadful complications of the disease ; and the one who 
dares to proclaim the possibility of cutting short the lengthy course, 
courts everlasting infamy! All the same, the severest attack of 
whooping-cough properly treated may be rendered almost innocuous, 
or at least free from grave consequences. 

Treatment. — As soon as pertussis is suspected the patient should be 
isolated, and given pertussis vaccines (3 or 4 doses) as a prophylactic. 
Immunization should also be resorted to in all the other children coming 
in contact with the patient. Isolation should be practiced principally 

* Statistics compiled by Morse from the United States Public Health Reports show that 
comparative death rates per hundred thousand are as follows: 

Whooping-Cough 11.4 per cent. 

Scarlet Fever 11.6 per cent. 

Measles 12.3 per cent. 

Diphtheria 21.4 per cent. 

He states, furthermore, that 94.5 per cent of the deaths from whooping-cough in the United 
States occur in children under five years of age, as follows: 

Under one year of age 57 per cent. 

In the second year 23 per cent. 

In the third year 8 per cent. 

In the fourth year 4 per cent. 

In the fifth year 2y 2 per cent. 

It can, therefore, be seen that the mortality from whooping-cough is higher in those of tender 
years — being more than twice as high under one as between one and two; and more than five 
times higher under two years than between two and five. If, to. these statistics, we add many 
of the reported deaths from bronchopneumonia supervening on whooping-cough, the mortality 
from the latter would be still larger. 



SPECIFIC COMMUNICABLE DISEASES 433 

during the expectorating period — at least three weeks. The sputum 
should be collected in tissue paper or gauze and immediately destroyed. 
Fresh air being the most essential and efficient therapeutic measure, 
the child should, except in the presence of grave complications, be 
kept outdoors the greater part of the day, and the rooms constantly 
aired with the patient indoors. Whenever possible, two or more 
rooms should be made use of. The food should be bland and strength- 
ening, and given in small amounts, preferably after the paroxysms. 
The clothing should correspond with the season of the year. We pos- 
sess no ideal specific against the disease, yet pertussis vaccine* (in 
gradually increasing doses from 500,000,000 to 2,500,000,000), adminis- 
tered at first daily and later once or twice a week, undoubtedly 
influences the course of the disease very favorably — even though not 
specifically. Moreover, a great deal can be done to lessen the number 
and severity of the paroxysms by resorting to the following medicinal 
agents : 

I£ Olei Eucalypti 3 ii 8.00 

Tr. Benzoini Comp. q. s. ad f 5 ii 60.00 

M. 
S. — One teaspoonful in a pint of hot water to be 

used as an inhalation through a croup kettle three 

times a day. 

IJ Quinine Ethyl Carbonate or 

Diquinine Carbonic Ester (Euquinine 

or Aristochin) 3 ss 2.00 

Syr. Simplicis 5 ii 60.00 

M. 
S. — One teaspoonful every two to four hours, ac- 
cording to the severity of the paroxysms, for a child 
three years old. 

In older children the subsulphate of quinine or qui- 
nine tannate may be given instead. 

I£ Creosoti Carbonatis 3 iv 15 00 

S. — Two drops for every year of the child's age. 

I wish to direct particular attention to "the marked antispasmodic 
value of calcium and sodium hypophosphites in mitigating and often 
completely arresting the "whoop" of pertussis. I have been led to ad- 
minister these drugs after noting the close resemblance between the 
manifestations of laryngeal spasm of spasmophilia (spasmus glottidis) 
and those of whooping cough and observing the beneficent action of 
lime and soda hypophosphites in spasmophilia. Furthermore, it 
seemed to me quite plausible to assume that, as is claimed in spasmo- 



*It should be used within four months of the date of manufacture. (W. C. Davison, 
Jour. Am. Med. Assn., Jan. 22, 1921.) 



434 DISEASES OF CHILDREN 

philia {e.g., in tetany), the whoop of pertussis may also be due to 
some functional disturbance in the parathyroids, arising traumatically 
as the result of the harassing cough during the earlier stages of per- 
tussis. 

These preparations do not in the least interfere with the action of 
any of the others generally employed, but on the contrary, combine 
well with them, as for example in the following mixture : 



Creosoti Carbonatis 3 i 


4.00 


Syr. Calcii et Natrii Hypophosphitum g i 


30.00 


Pulv. et Mucilaginis Acaciae q. s. 




Aquae Anisi q.s.ad f % ii 
M. 


60.00 


S. — One teaspoonful every four hours, for a child 


three years old. 





My results thus far have been very encouraging. 

Whenever necessary a small dose of some morphine preparation 
with or without 2 grains of antipyrin may be administered to induce 
rest or sleep, and where the heart is weak, a fresh infusion or the tinc- 
ture of digitalis will prove a grateful addition. Numerous other reme- 
dies have been found serviceable, but caution is commended in their 
promiscuous use. 

The paroxysms may frequently be controlled by pulling the lower 
jaw downward and forward. This manipulation is harmless and pain- 
less. Its application is contraindicated only in the presence of food 
in the mouth or esophagus. 

A silk elastic abdominal belt (Kilmer) is useful to allay vomiting 
and the severity of the paroxysms. Chloroform anesthesia will some- 
times relieve the attacks almost magically and should be tried in 
desperate cases, especially in those associated with convulsive seizures. 

Complications and sequela? arising should be treated according to 
indications. 



B; Ext. Belladonnse Fl. 




m. iv 


0.25 


Vini Ipeeacuanhse 




m. xvi 


1.00 


Nat. Bromidi 




gr. xvi 


1.00 


Syr. Amygdal. 




3iv 


15.00 


Aq. Destil. 


q- 


s. ad f 3 ii 


60.00 


M. 






S. — One teaspoonful every 


two 


to four hours, for 


a child two years old. 









Whooping" Cough in the Newborn 

The following remarks are based upon the observation of 16 cases 
of pertussis in infants of from nine to twenty days old. In all of these 



SPECIFIC COMMUNICABLE DISEASES 435 

babies the source of infection could be traced to members of the im- 
mediate family, although in some of them the positive history was 
not immediately apparent. For example, in one case the source of 
infection was traced to a grandfather, sixty-four years old, who for 
a few weeks had been suffering from a paroxysmal loose cough ac- 
companied by semifainting spells. He had been treated for cardiac 
asthma. Six infants contracted the disease from their mothers who 
had been suffering from a protracted cough, supposedly bronchitis, 
because of the absence of the characteristic whoop. As these infants 
during the first few days after birth were entirely free from any signs 
of nasopharyngeal or bronchial catarrh, there is every reason to be- 
lieve that the infection took place after birth, and, furthermore, that 
immunity was not conferred upon them by their mothers. In the re- 
maining nine babies the source of infection was readily discerned, since 
one or more members of the family were afflicted with the disease. 

The cases of whooping cough in the newborn thus far recorded are 
exceptionally few. Among them may be cited the classic cases of 
Bouchut, Rilliet, Barthez, Currier, Watson, Neurath, and Holt 
("Twentieth Century Encyclopedia" and Pfaundler and Schloss- 
mann's "Handbook of Pediatrics "). The meagerness of the litera- 
ture on the subject, notwithstanding the extremely high mortality 
which prevails among these cases, tends to emphasize the apparent 
levity with which pertussis is looked upon even by the profession. Of 
course, due allowance must be made for the fact that a great many 
infants succumb to the disease before a correct diagnosis has at all 
been arrived at. For be it remembered that the symptomatology of 
pertussis in the newborn differs greatly from that observed in older 
children. Whereas in the latter, as already stated, we are usually 
able to distinguish three characteristic stages of the disease, thus, 
stadium catarrliale, convulsivum, and decrementi, in the newborn the 
catarrhal and paroxysmal stages are confluent, while the catarrhal stage 
is so brief in duration as entirely to escape observation. Beginning 
with occasional mild sneezing or coughing a few days after birth, it is 
all at once noticed that the baby is struggling for air with each fit of 
coughing, turns blue and even black in color, and after a few expul- 
sive efforts of expectoration, followed by gagging and trickling out of 
frothy mucus from its mouth, the infant falls back pale and exhausted, 
in semicoma as it were. The paroxysms return at shorter or longer 
intervals, as a rule, every five to ten minutes. The attacks of apnea 
are almost invariably associated with temporary arrest of the heart's 
action, and it is not at all unusual for some delicate infants to succumb 



436 DISEASES OF CHILDREN 

during a paroxysm. I witnessed it in 3 cases — twelve and fifteen days 
old respectively. Of the remaining cases under my observation 4 re- 
covered, 7 died from bronchopneumonia, or rather hypostatic or passive 
pulmonary congestion, 1 of cerebral hemorrhage and 1 from inanition. 
One of the cases of bronchopneumonia was complicated by rupture of 
the pulmonary alveoli (pneumohypoderma, q.v.). 

The cerebral hemorrhage complicating pertussis is usually localized, 
giving rise to mono- or hemiplegia, and when confronted with an in- 
fant that has been delivered instrument ally and shows distinct signs 
of forceps traumatism, the diagnosis is apt to be greatly obscured. In 
the absence of a positive history of whooping-cough, and more espe- 
cially in the early stage of the disease, it is often also very difficult 
to decide, whether or not we are dealing with congenital heart disease 
or hypertrophy of the thymus gland, since in both these affections more 
or less marked cyanosis predominates. In the differential diagnosis 
it is well to bear in mind that in congenital vitia cordis, the cyanosis 
is either permanent or becomes apparent only during fits of crying. 
Furthermore, physical examination usually reveals definite signs of 
heart disease, such as murmurs or pronounced anatomic malformations. 
An enlarged thymus sufficiently marked to produce grave symptoms 
usually discloses, on percussion, distinct dulness or flatness over the 
upper portion of the sternum, particularly to the left as low as the 
second rib and often also to the back between the scapulae. Further- 
more, the paroxysms of asphyxia in thymus hypertrophy are much 
less marked and less frequent than in pertussis. Mild cases of whoop- 
ing-cough may sometimes be mistaken for atelectasis pulmonum, but 
this condition is usually preceded by asphyxia neonatorum and is not 
accompanied by sudden attacks of coughing. Some aid in the diag- 
nosis may be derived from a careful blood examination which in per- 
tussis generally shows a pronounced augmentation in the leucocytes, 
but, as there is always a great relative increase in the lymphocytes in 
the blood of the newborn, this test is not as decisive in infants as in 
older children. However, this test may serve to detect the immediate 
source of the infection and should be applied to the other members of 
the family who happen to be afflicted with a recalcitrant cough. 

Treatment. — In view of the extremely high mortality in pertussis neo- 
natorum our main therapeutic efforts must be directed toward prophy- 
laxis. It devolves upon the obstetrician particularly to guard against 
transmission of whooping-cough to the newborn, be it by the mother 
or any other member of the immediate family. Even if there is only 
a suspicion, the infant must be promptly isolated, and with further 



SPECIFIC COMMUNICABLE DISEASES 437 

corroborative evidence of the existence of the disease, immediately 
immunized. Judging from personal observation, the administration of 
prophylactic pertussis vaccine in full doses is absolutely harmless 
even in the youngest of infants. If the mother is suffering from 
whooping-cough, we must stop her nursing of the infant, at least until 
the infant has been thoroughly immunized. In a number of cases, 
owing to the frequency and severity of the paroxysms, the infants 
are totally unable to nurse at the breast, in which eA*ent it will be 
found advantageous to feed them on the breast milk by means of 
Breck's feeding tube, in small quantities, and at short intervals, in 
the same manner as practiced with premature babies. The active 
treatment is very unpromising. In 6 of my cases pertussis vaccine 
as a therapeutic agent proved useless. Some benefit may be derived 
from the early administration of bromides and lime and soda hypophos- 
phites (see pp. 433, 434) to arrest the frequency of the spasms ; of ipe- 
cacuanha, to facilitate expectoration and thus to hasten the termination 
of the paroxysms, and of strophanthus. to sustain the baby's heart 
action. The bromides, either potassium or sodium, should be given 
in sufficiently large doses to induce more or less profound sleep. One 
grain every three to six hours in the beginning and less frequently 
thereafter usually answers the purpose. The ipecac, preferably the 
syrup, should be given in from 3 to 5 minim doses until the cough 
has thoroughly loosened, and whenever the chest and throat become 
choked up by the tenacious mucus, it is occasionally of advantage to 
increase the dose of the ipecac sufficiently to produce emesis. Vom- 
iting, by the way, is Nature's method of relieving the paroxysms 
of pertussis. The dosage of the tincture of strophanthus should 
vary with the condition of the infant's heart. Generally, % to 1 
minim, three times a day, will be found sufficient. Finally, it is most 
important to remember that an abundance of fresh air is the sine qua 
non in whooping-cough, and that, especially in delicate babies, oxygen 
by inhalation is worthy of trial. 

TUBERCULOSIS 

Introductory Remarks 

(Prevention of Tuberculosis) 

Without denying the possibility of antenatal direct bacillary trans- 
mission of tuberculous disease from parents to offspring (six cases of 
undoubted fetal tuberculosis are on record), it may be set down as ab- 
solutely certain that, with but very few exceptions, tuberculosis in in- 



438 DISEASES OF CHILDREN 

fancy and childhood, as in adolescence, is acquired as a result of post- 
natal* infection by the tubercle bacillus of Koch. The bacillus invades 
the human organism principally through the respiratory (by inhala- 
tion in about 80 per cent) and alimentary tracts (by ingestion in about 
15 per cent, often by swallowing tuberculous material derived from the 
lungs) ; less frequently through the skin or mucous membranes (slight 
traumatism, skin eruptions, etc.), and occasionally also through the 
blood, when broken down tuberculous foci are carried into the circu- 
lation. The readiness with which infection occurs depends chiefly upon 
the power of resistance of the patient and the environment in which 
the patient is forced to live. This explains the greater frequency of 
tuberculous disease in children of tuberculous parentage. An under- 
mined constitution from one cause or another (most particularly acute 
infectious diseases, such as measles, whooping-cough or influenza) forms 
an easy prey to the tuberculous germ and, varying with the primary 
seat of the infection, the natural recuperative strength of the tissues 
involved, and the therapeutic measures adopted to resist and combat 
further systemic invasion, tuberculous disease may remain localized or 
become general, and pursue an acute or chronic course. 

The successful management of tuberculosis rests upon a thorough ap- 
preciation of the aforementioned facts. We possess no specific remedy 
against tuberculosis, once fully established, but the disease is certainly 
preventable and in its incipient stage curable — a great deal more than 
can be said of a number of nontuberculous, organic affections. 

Prevention of tuberculosis in a child must begin immediately after 
its birth. Every infant should be removed from a tuberculous envi- 
ronment ! The air the infant is to breathe should be pure, the room it is 
kept in sanitary and well ventilated, though warm enough to suit its 
needs. From earliest infancy the child should be gradually accus- 
tomed to outdoor air, and, as he grows older, he should spend most of 
the day outdoors, except when the weather is particularly bad. In this 



*In 988 children examined by von Pirquet the reaction was found positive: 

to 3 months per cent 4 to 6 years 50 per cent 

3 to 6 months 5 per cent 6 to 10 years 57 per cent 

6 to 12 months 16 per cent 10 to 14 years 68 per cent 

1 to 2 years 24 per cent 

Bass and Hess, Jour. A. M. A., Jan. 11, 1919, made the following observations: 

AGE DISTRIBUTION OE PATIENTS REACTING POSITIVELY TO CUTANEOUS OR INTRACUTANEOUS TEST 





NUMBER 
TESTED 


REACTING POSITIVELY 




NUMBER 


PER CENT 




51 
38 
29 

45 
28 


4 

6 

5 

14 

12 


7 8 


6-12 months 


15.8 


1-2 years 


17.2 


2-3 vears 


31.1 


3-5 years 


42.8 







SPECIFIC COMMUNICABLE DISEASES 



439 



event he should remain well dressed in front of an open window. Spe- 
cial attention should be paid to his breathing. Any obstruction to free 
nasal breathing, be it adenoids, hypertrophy of the tonsils, or of the 
nasal mucous membrane, or deformity of the nasal bones, should be 
treated or removed without delay. The child should be taught to breathe 
deeply — few children know how to breathe, as is readily evinced in ex- 
amining a child's chest. Infants should be encouraged to cry off and 
on, and older children to recite and sing in the open air. As the child 




Fig-. 101. 




Fig. 102. Fig. 103. 

Figs. 99-103. — Breathing exercises. 

grows old enough intelligently to follow instructions, he should be 
taught the following breathing exercises : 

1. Deep inhalation, while raising the arms to a horizontal position; 
slow exhalation, bringing the arms down (Fig. 99). 

2. Deep inhalation with the arms placed lightly upon the front of 
the lower portion of the chest ; slow exhalation, bringing the arms down 
(Fig. 100). 

3. Deep inhalation, while bringing the arms first to a horizontal posi- 
tion, then above the head, and lastly — while still holding the breath — 



440 DISEASES OF CHILDREN 

bending the upper body backward; slow exhalation, while lowering the 
arms sideways (Fig. 101). 

4. Deep inhalation, while bringing the hands together in front of 
the abdomen, and from here slowly along the thorax and chin above 
the head and as far as possible back of it ; slow exhalation, bringing the 
hands down to the original position (Fig. 102). 

5. Deep inhalation, while bending the upper body as far back as pos- 
sible, with the hands fixed on the hips; slow exhalation, while resuming 
original position (Fig. 103). 

During the breathing exercises the child assumes the position of mili- 
tary "attention." He breathes with the mouth closed, occupying about 
four seconds for inhalation, four seconds for retention of the air and 
three seconds for exhalation. The exercises should be practiced either 
outdoors or in front of an open window; at first four or five times a 
day, but, after the child gets accustomed to expand his chest properly 
during the respiratory act, only once or twice a day or not at all. The 
breathing exercises, like any other physical work, should not be 
overdone, and never continued too long as to become tiring. As pro- 
longed holding of the breath interferes with the normal heart's action, 
it is contraindicated in organic heart disease. Short-distance running, 
and peaceful outdoor games (hand-ball, basket-ball, and tennis) also are 
helpful to expand the lungs. The principal benefit derived from these 
breathing exercises is the purification of the lung tissue by the free in- 
flow and uniform distribution of oxygen, thus preventing pulmonary 
congestion which acts as a predisposing cause of tuberculous infection. 

What pure air does for the prevention of pulmonary tuberculosis, 
suitable feeding from birth will do for the prevention of tuberculosis 
of the aliment ary tract. It is highly essential ever to bear in mind that 
tubercle bacilli rarely, if ever, survive the action of normal digestive 
juices. The gastroenteric tract, especially the stomach, therefore, should 
be spared pathologic alteration. Breast milk of a healthy mother or 
wet-nurse should at all times be the food of choice for an infant up to 
nine months old. With increasing age the dietary should undergo a 
gradual change, always selecting, however, such articles of food as will 
best accomplish the object in view, i. e., ample nutrition for the growth 
and development of the child with least possible injury to the digestive 
organs. Overfeeding especially is to be avoided. It goes without saying 
that contaminated food should never form a part of the dietary. Cow's 
milk of doubtful purity should be sterilized, and other articles of food 
of such character boiled. The teeth should receive special attention, 
since cavities of decayed teeth not rarely harbor tubercle bacilli and 



SPECIFIC COMMUNICABLE DISEASES 441 

early loss of the permanent teeth forms one of the principal causes of 
acute and chronic dyspepsia — as a result of insufficient mastication of 
the food — and indirectly enhances the development of tuberculosis. 
Children should be taught to eat slowly, and to refrain from eating be- 
tween meals. 

Tuberculous infection through the skin and contiguous mucous mem- 
branes should be guarded against by scrupulous cleanliness of these 
structures, avoidance of external injury and skin eruptions, and by im- 
mediate treatment of open wounds and all such skin lesions as are asso- 
ciated with itching and compel scratching. Those intrusted with the 
care of babies and older children should be instructed to give their 
charges a tub bath in the evening and a sponge bath in the morning 
followed by gentle rubbing of the entire body. Of course, the bathing 
should include careful cleansing of the nails, which should be kept 
clipped short, of the ears, of the nose and scalp, and, in older children, 
also of the teeth. From earliest infancy children should very gradually 
get accustomed to cool sponge baths. At first the infant may be given 
a cool alcohol sponge bath, and after toleration has been established 
the alcohol should gradually be replaced by water, and finally by full 
cool tub or shower baths (except during cold winter months). The 
advisability of cleansing the infant's mouth is still a matter of opinion. 
I am inclined to favor gentle wiping of the infant's mouth twice daily 
with a cotton swab dipped in sterile water. Older children should be 
taught the use of a soft brush for the teeth and an antiseptic gargle 
for the mouth and throat. The importance of early removal of naso- 
pharyngeal obstruction to breathing has already been alluded to. This 
question cannot too strongly be emphasized, for the adenoid tissue, in 
addition to interfering with free respiration, is surely one of the most 
rampant sources of tuberculous infection. Skin eruptions should at 
once be combated. This refers especially to running sores from what- 
ever cause, and to all skin diseases which sooner or later lead to mac- 
eration and denudation of the skin. Intertrigo in infants is best pre- 
vented by frequent changing of the diapers and keeping the buttocks 
perfectly clean and dry. The child should be kept from scratching the 
affected portions of the skin by immediate application of antipruritic 
drugs and by restraining the child 's hands by means of one of the many 
useful contrivances. Open wounds should be dressed antiseptically un- 
til healed. Vaccination wounds especially should receive careful at- 
tention. Certain, though it be, that latent tuberculosis is occasionally 
lighted up through vacinnation, and that tuberculosis has in very ex- 
ceptional instances been traced to vaccine infected by tubercle bacilli, 



442 



DISEASES OF CHILDREN 



it is absolutely settled that the great majority of cases of tuberculosis 
following* vaccination are the result of direct bacillary infection through 
an unprotected vaccination wound. 

Effective as these local measures are in the prevention of tuberculosis, 
their efficiency is very insignificant as compared with the natural de- 
fensive resources of a healthy constitution. Our aim, therefore, should 
be directed chiefly, from earliest infancy, to rendering the patient, so to 
say, immune against tuberculosis. This is best accomplished by outdoor 
life, wholesome nutrition, and sanitary environment. Those showing 
a tendency to remain delicate in health should reside in the country. 

Miliary Tuberculosis 

(Hasty Consumption) 
This disease is characterized by wide distribution of the tuberculous 
lesions. The latter are from a pinhead to a millet seed in size, gray 




Fig. 104. — Acute pulmonary miliary tuberculosis (cut surface of the lung). a. 
So-called obsolete tubercle (old encapsulated caseous focus), h. Induration, c. 
Caseous, partly agminated nodules (transverse section of caseous bronchi), d. Sub- 
miliary noncaseated tubercle in the true lung tissue, e. Tubercle of the pulmonary 
pleura. One-half natural size. (Langerhans and Brooks, F. A. Davis Co.) 



SPECIFIC COMMUNICABLE DISEASES 



443 



or yellow in color, and firm in consistence. They are found scattered 
throughout almost all the organs and tissues of the body, but especially 
the lungs and bronchial glands, intestines and mesenteric glands, the 
liver, spleen, kidneys and bladder, and the brain and its coverings. 
They may remain latent for some time, or give rise to indefinite symp- 
toms, such as anorexia, dyspepsia, gastroenteritis, and emaciation, or 
symptoms of pulmonary phthisis. The outbreak is often determined by 
some intercurrent disease or traumatism, but once established it usually 
runs a very violent course. 




Fig. 105. — Miliary tuberculosis of the lungs in a child nine years old. 

The temperature rises, is intermittent, hectic in character, only rarely 
drops to normal, and may be associated with chills and sweats. In the 
beginning, especially in the absence of marked pulmonary symptoms, 
and in the presence of a large liver or spleen, or both, the disease greatly 
resembles malarial fever or typhoid. Careful examination, however, 
reveals the absence of the malarial or typhoidal germs in the blood. 
Where signs of pulmonary disease predominate, it is readily confounded 
with lobular pneumonia. In such cases the diagnosis is extremely diffi- 
cult and often can be decided only by microscopic examination of the 



444 DISEASES OF CHILDREN 

sputum (frequently negative) and the tuberculin test. As the disease 
advances the diagnosis may be based upon the extreme emaciation, mul- 
tifariousness of the symptomatology, the violence and persistence of the 
febrile attacks and x-ray examination. 

The symptoms and course of the disease differ with the seat of the 
lesions. The lungs almost invariably show signs of consolidation (dul- 
ness, crepitant rales, dyspnea, cyanosis, short cough), and the intes- 
tines rarely escape involvement. In some cases brain symptoms (ap- 
athy, jactitations, stupor, localized convulsions, tubercles in the choroid, 
etc., up to a typical picture of meningitis) predominate; in others 
again, symptoms of disturbed circulation (marked cyanosis, edema, 
rapid feeble pulse, anemia and exhaustion, etc.) prevail. The latter 
phenomena usually precede the fatal issue, which generally occurs 
within from four to eight weeks. Cases running a subacute course may 
last a few weeks or months longer, are not rarely erroneously diagnosed 
and treated as marasmus, their true nature not being detected until 
postmortem. It is in those cases, particularly, that the von Pirquet 
or intracutaneous reactions and a roentgenogram are so helpful in the 
diagnosis, and should always be resorted to early. Then and then only 
may our efforts to arrest or possibly cure the disease prove successful. 

For details of treatment, see p. 449. 

Phthisis Pulmonum 

(Tuberculosis of the Lungs and Bronchial Glands) 

The lungs proper, the bronchial glands, or both, may be the pri- 
mary seat of tuberculous deposits. The upper lobes are more frequently 
affected than the lower, and the portions adjacent to the bronchial 
glands more so than the remaining parts. The pathologic changes con- 
sist essentially in the formation of variously sized caseous nodules filled 
with colonies of tubercle bacilli and large so-called giant cells, and sub- 
sequent softening and breaking down of the nodules, forming cavities 
which may vary in size frcm a pea to a walnut, or larger. There is usu- 
ally an endarteritis with miliary tubercles in the walls of the blood ves- 
sels. The pleura is thickened and the lining of the larynx, trachea and 
bronchi ulcerated. In some cases, especially in those receiving early 
and suitable treatment, the tuberculous process is arrested by encap- 
sulation of the necrosed structures by newly formed connective tissue, 
leading to contraction and formation of a firm cicatrix. In this event 
the enclosed masses are in part absorbed, and in part calcified. The tu- 
berculous affection of the bronchial glands also consists in hyperplasia 
and caseous degeneration. This process usually (sooner or later) ex- 



SPECIFIC COMMUNICABLE DISEASES 



445 




Fig. 106. — Tuberculosis. Horizontal sec- 
tion through the tuberculous lower lobe of 
the right lung of a two-year-old child, (a) 
caseous focus in the region of the anterior 
border; (6) nontuberculous posterior bor- 
der; (c) transverse section of bronchus; 
{d, d 1 ) caseated lymph glands; (e) pul- 
monary vein; (/) point of adhesion of the 
vein e with the lymph gland d 1 ; (g) 
tubercle in the lymph vessels of the lung 
parenchyma; (h) periarterial, (i) peribronchial, (I') perivenous tubercles; (?) 
lymph-vessel tubercles of the pleura; (w) tubercle in the connective tissue of the 
hilus of the lung, x 3 - (Ziegler.) 



446 DISEASES OF CHILDREN 

tends to the contiguous structures, exerts pressure upon the adjacent 
blood vessels, nerves, and bronchi, and, after forming adhesions, may 
displace, erode and perforate these parts. In this manner not only may 
tuberculous infection be rapidly carried throughout the lungs and more 
distant organs (producing an acute or chronic tuberculous pneumonia), 
but perforation of a blood vessel or bronchus, or entrance of caseous 
masses into the trachea may unexpectedly produce sudden and often 
fatal hemorrhage or suffocation. 

The symptoms vary with the primary seat of the lesion and the sub- 
sequent pathologic changes. A small tuberculous focus, be it in the 
lung or bronchial glands,* rarely gives rise to any definite clinical phe- 
nomena. As a rule, in the beginning the disease pursues a latent course. 
This is especially true in infants. The child is pale, loses in weight, 
often notwithstanding good appetite, gets tired on the slightest exer- 
tion, "hems" and coughs a little, and the temperature rises somewhat 
in the evening. Sooner or later the symptoms become more distinct. 
Emaciation, cough, and gastrointestinal disturbances increase in se- 
verity; the child suffers from dyspnea, and, if the bronchial glands are 
involved, from paroxysmal attacks of coughing, greatly resembling per- 
tussis (the cough has a metallic timber with a characteristic expira- 
tory whoop). This cough is the result of pressure exerted by the en- 
larged bronchial glands upon the pneumogastric and recurrent nerves. 
Physical signs, however, are often still wanting. Occasionally, percus- 
sion over the mediastinum may reveal increased dulness, but in infants 
this symptom is not pathognomonic in view of the physiologically large 
thymus. Indeed, the disease is often not detected until grave, not rarely 
fatal, symptoms (e.g., hemoptysis, hectic fever) announce the serious- 
ness of the condition. The diagnosis of pulmonary phthisis in infants, 
therefore, must be based upon the entire clinical picture, rather than 
the local symptoms. If, for example, bronchial catarrh is associated 
with progressive emaciation, multiple glandular swellings, protracted 
diarrhea and possibly also some bone or joint disease, the diagnosis of 
tuberculosis is justifiable, even though careful examination of the thorax 
fails to reveal pulmonary consolidation or cavity. For corroborative 
evidence we should carefully examine the child's sputum (obtained by 
means of a catheter introduced to the base of the tongue) for tubercle 
bacilli, and employ the tuberculin and complement-fixation tests and the 
Roentgen-ray. 

In older children the symptomatology of pulmonary tuberculosis is 
essentially the same as in adults. Its onset is usually insidious, and 



*According to D'Espine, bronchophony heard along the spinal column btlow the second or 
third dorsal vertebra points strongly towards enlargement of the bronchial lymph nodes. 



SPECIFIC COMMUNICABLE DISEASES 



447 



quite frequently follows delayed convalescence from some acute disease, 
such as pertussis, morbilli, broncho- or lobar pneumonia, and the like. 
The child fails fully to recuperate, is pale, thin, and feeble, suffers from 
slight shortness of breath, dry cough, chilliness and fever. At first 
these symptoms are more or less masked, but as the lung destruction ad- 
vances the symptoms and physical signs grow rapidly worse. The cough 
becomes persistent, often distressing, especially at night, and attended 
by expectoration and pain. The fever is intermittent or remittent (hec- 
tic) in character. It is usually normal or slightly above normal in 
the morning, and from two to three degrees higher in the evening. It 
is often preceded by chilliness and followed by profuse sweating. Dur- 
ing the height of the fever the cheeks are usually brightly flushed and 




Fig. 107. — Phthisis pulmonum in a child twenty months old. 



contrast strongly with the remaining portions of the face which are 
deathly pale. Night sweats are often observed early in the course of 
the disease. With further progress of the disease the expectoration 
becomes mucopurulent or purulent, nummular, and streaked with 
blood; the fever more irregular, and attended by great exhaustion, and 
the emaciation profound. 

The agony may be further aggravated by the concurrence of a num- 
ber of painful complications. The disease may extend to the pleura 
(pleuritis sicca or with serous or hemorrhagic effusion) ; to the trachea 
and larynx (dysphagia, frequent hemorrhages, and aphonia) ; to the 
alimentary tract (colliquative diarrhea); and where the bronchial 
glands or pleura are involved, to the pericardium (pericarditis). By 



448 DISEASES OF CHILDREN 

this time, and sometimes at an earlier period the child presents a char- 
acteristic, ghastly appearance. The cheeks are hollow, the eyes and 
temples sunken, the bones of the face and the ears prominent, the nose 
is pointed and drawn, and the hair thinned, lusterless and brittle. The 
face is either deathly pale or marked by florid redness along the zygo- 
matic regions. The neck is wasted, the supra- and subclavicular spaces 
are depressed, the shoulders stoop, and the shoulder blades project 
wing-like far bej^ond the shrunken, immovable spine. The thorax is 
narrow and contracted, and the ribs overlap each other, effacing the 
intercostal spaces. The abdomen is flat or deeply sunken below the 
strikingly prominent pelvic bones. The extremities are mere skin and 
bone and their epiphyseal ends seem greatly enlarged as they protrude 
through the wasted, arid integument. 

The physical signs vary with the stage, location and extent of the 
lesions. As already mentioned tuberculosis of the bronchial glands 
ma}^ by physical examination entirely escape observation. The same 
holds true of cases where the tubercles are scattered throughout the 
lungs and do not coalesce. On the other hand, where pulmonary con- 
solidation (tuberculous pneumonia) occurs early and progresses rap- 
idly, the physical signs resemble those of ordinary pneumonia, i. e., dul- 
ness on percussion, prolonged expiration, increased vocal fremitus, fine, 
coarse and crepitant rales, and bronchial breathing. To these may be 
added the physical signs of dry or serohemorrhagic pleurisy (see p. 
330), which frequently accompanies phthisis pulmonalis. Where cav- 
ities are formed, the physical signs consist of cavernous respiration, 
bronchophony or pectoriloquy. The percussion resonance is amphoric, 
if the walls around the cavity are thin and tense ; cracked-pot sound, if 
the walls are thin and relaxed, and dull, if the walls are thick. If pneu- 
mothorax is present, the percussion sound in tympanitic, and the respir- 
atory murmur is lost; while hydropneumothorax gives rise to tympan- 
itic resonance above the water line, dulness below, and metallic tink- 
ling on auscultation. 

The poignancy of the clinical picture just depicted notwithstanding, 
errors of diagnosis are quite possible. Pulmonary phthisis may readily 
be confounded with bronchial dilatation, localized empyema, fetid 
bronchitis, pulmonary gangrene, and syphilis. In view of the prognos- 
tic importance of an early diagnosis of tuberculosis, it is imperative to 
employ every means of diagnosis (especially repeated examination of 
the sputum, the tuberculin reaction and the x-ray) to clear up all doubt. 

The course and duration of phthisis pulmonum ranges within very 
wide limits. Not only is it true that tuberculosis may proceed a latent 



SPECIFIC COMMUNICABLE DISEASES 449 

course for months or years and suddenly break out — often after some 
trivial cause, such as vaccination, measles, etc. — and rapidly end fa- 
tally under symptoms of lobular or lobar pneumonia and the like, but 
postmorten examinations have repeatedly established the fact that after 
existing for some time, with or without indications of their presence, 
tuberculous lesions may heal spontaneously never to return. As a rule, 
however, pulmonary phthisis in young children runs quite an acute 
course. Unless the disease is arrested in its incipiency, infants usually 
succumb to it within frcm four to eight weeks either from the imme- 
diate effects of the pulmonary lesions, or as a result of generalized tu- 
berculosis not rarely of the miliary variety. In older children the dis- 
ease pursues a less violent course, and, as in adults, shows a tendency 
to remain localized at its originally infected focus until a very late stage 
of the disease. If the tuberculous process is allowed to continue, death 
invariably occurs in from two to three years or earlier — either from 
asthenia (with symptoms of gradual exhaustion, profound anemia, 
dropsy, etc.) or from apnea (suffocation by sudden hemorrhage, rup- 
ture of large cavity, pulmonary edema, etc.). On the other hand, if the 
tuberculous process is detected in its incipiency — which is quite possi- 
ble with the existing modern diagnostic methods, more especially the 
tuberculin tests and x-ray — and immediately and energetically treated, 
the chances for arrest and eventual cure of consumption of the lungs 
are very good indeed. 

Treatment. — The treatment comprises outdoor life, good food, per- 
sonal hygiene, and symptomatic medication. Whenever possible, tu- 
berculous children should be sent to the country regions where the 
climate is dry and of equable temperature, so as to allow the pa- 
tients to enjoy outdoor air the greater part of the day. The climates 
of New Mexico, Arizona, and Egypt are best suited for the purpose, al- 
though a great many patients will be found to do well in Colorado, 
in the Adirondacks and Sullivan County of New York, in Montana, 
Wyoming and North Carolina. Those financially incapacitated to 
take advantage of these climates should be removed to climatically 
less favorable mountain regions or even to ordinary city suburbs, but 
at all events should not be left to perish in overcrowded, unsanitary 
tenement districts. It is often of great advantage to place the child 
in an up-to-date sanatorium (if possible in a private room) since 
prophylactic and active therapeutic measures are more accurately 
enforced (and with less resistance on the part of the patient) under 
the supervision of a reliable physician and nurse of a properly con- 



450 



DISEASES OF CHILDREN 




SPECIFIC COMMUNICABLE DISEASES 451 

ducted sanatorium, than at the patient's residence among his timid 
and sympathetic immediate relatives. 

The diet should vary with the age of the patient, but should be 
highly nutritious and liberal. Milk, meat, eggs, fresh fish, oatmeal, 
peas, beans and lentils, carrots, spinach, asparagus, potatoes, etc., in 
addition to an ample supply of bread and butter, should form the prin- 
cipal components of the regular meals. Between meals the child 
should receive plenty of fresh fruit or fruit juices, and, to satisfy 
its craving for condiments, a moderate supply of sugar, sweet or milk- 
chocolate or calf's foot jelly, and the like. 

The room occupied by the patient should be large and airy, and its 
windows open day and night, irrespective of season or weather. The 
child should sleep alone. In addition to a warm cleansing soap bath 
once a week, it should receive a cool sponge bath twice a day fol- 
lowed by brisk rubbing of the entire body. The underwear should be 
of thin silk or wool, and the outer garments should vary with the 
season of the year — always sufficient to keep the patient comfortably 
warm. In the absence of fever or circulatory disturbance, light 
exercise that does not fatigue acts very beneficially. Horseback rid- 
ing is highly to be recommended. 

The value of drugs as auxiliaries in the successful management of 
pulmonary tuberculosis should not be underestimated. It is not very 
long ago that creosote was almost universally hailed as the specific 
against consumption. And, while its curative claims had been (as 
is always being done with new methods of treatment) grossly exag- 
gerated,* its efficiency to relieve distressing symptoms (useless cough) 
and to aid in arresting the further spread of the tuberculous lesion 
cannot wholly be denied. Creosote should be given in small grad- 
ually increased doses, well diluted in milk, malt extract or red wine. 
The hypophosphites also are deserving of trial, and may advanta- 
geously be combined with malt and cod liver oil, as follows : 



I£ Olei Morrlruse I iv 


120.00 


Extr. Malti Si 


30.00 


Syr. Hypopliosph. Comp. § i 


30.00 


Glycerini 3 iv 


15.00 


Pulveris Acaciae 3 iv 


15.00 


Aq. Cirmamomi q.s. ad f § viii 


210.00 


M. 




S. — Two teaspoonfuls three times a day. 





*Most recently Chaulmoogra oil has been brought to the front as an efficient antituberculosis 
remedy (Editorial Jour. Am. Med. Assn., lxxiv, No. 23, 1920.) 



452 



DISEASES OF CHILDREN 



The bowels should be kept open, and the appetite improved by 
means of bitter tonics, especially mix vomica and the compound tincture 
of cinchona. 

In incipient phthisis it is very rarely necessary to resort to opiates 
or its derivatives to check the cough, but when the latter is distress- 
ing, especially at night, those remedies should be cautiously adminis- 
tered as often as indicated. 

The management of advanced cases of tuberculosis of the lungs is 
essentially the same as in incipient cases, except that one is often 
called upon to arrest hemoptysis (ice bag to chest, morphine hypo- 
dermically),* and to check hyperidrosis (sponging of the body with a 
strong alum solution, atropine by mouth or hypodermically), and 
to strengthen the heart's action (digitalis and strychnine). In the 
presence of the aforementioned complications, however, very few 
children survive— do what you will. Like the flickering flame of the 




Fig. 109. — Tuberculosis of the brain (boy four years old). During the protracted 
course of the disease a marked hypertrichosis developed over the entire body, espe- 
cially the legs. 

candle end, after many ups and downs, slowly but surely, life is ex- 
tinguished — often at a time when the patient seems on the mend. 

Tuberculosis of the Brain 

Brain tuberculosis occurs in children (1) as a partial manifestation 
of general tuberculosis, (2) as tuberculous meningitis, and (3) as 
brain tumors. The brain lesions are essentially the same in the three 
clinical types of the disease. They consist in the deposit of tubercles 
in the brain substance which vary in size from a millet seed to that of 
a hen's egg. In tuberculous meningitis we find, in addition, inflam- 
mation of the pia mater of the brain and sometimes also of the cord 
and transudation into the ventricles {chronic hydrocephalus) . The 
tubercles are usually located in the gray matter — in the large ganglia, 



*Artificial pneumothorax may be resorted to in older children. 



SPECIFIC COMMUNICABLE DISEASES 453 

in the pons and in the cerebellum — and occasionally also in the white 
substance. During life, however, it is extremely difficult to determine 
the seat of the lesion, except when the latter is large enough to exert 
pressure on the vital structures which in their turn give rise to focal 
symptoms — as for example, paralysis of the cranial nerves in the dis- 
ease of the pons. In the absence of such symptoms tuberculosis of the 
brain may exist for months without being detected. This is especially 
true of brain tuberculosis associated with tuberculosis of other organs. 
As the disease progresses, the symptomatology becomes clearer. The 
child suffers from intense headache, convulsions, paresis or paralysis of 
some of the cranial nerves or extremities, but even then it is often 
only a matter of conjecture whether these pressure symptoms are due 
to tubercle or to other tumors. (See "Tuniors of the Brain," p. 645.) 
The diagnosis is least difficult when tuberculosis of the brain is mani- 
fested by meningitis. (See p. 614.) Here lumbar puncture and the 
complement-fixation reaction (q. v.) often help to clear up the diagnosis. 
Recourse should be had also to the tuberculin test, examination of the 
sputum for tubercle bacilli, and ophthalmoscopic inspection of the eyes 
for choroidal tubercules. 

Tuberculosis of the Abdominal Organs 

Aside from the intestinal tract and peritoneum, the spleen, liver, 
pancreas, diaphragm, omentum, suprarenals, and the urogenital sys- 
tem may also be the seat of tuberculous disease. Except in the rare 
instances of invasion of the abdominal organs by tubercle bacilli 
through the general circulation (blood or lymph channels), the ab- 
dominal organs usually become involved secondarily to intestinal or 
peritoneal tuberculosis. As a rule, these latter structures become 
infected primarily by swallowing of food, sputum or necrotic tissue 
from the nasopharynx contaminated by tubercle bacilli. 

Tuberculous Peritonitis 

This condition is the result of dissemination of tubercles over the 
peritoneum, omentum, and adjacent structures. The inflammation ex- 
cited by their presence gives rise to a serofibrinous or hemorrhagic 
exudation with gradual agglutination of the inflamed portions, case- 
ation and ulceration. Postmortem examination of cases of long stand- 
ing usually reveals involvement of the mesenteric and retroperitoneal 
glands, amyloid degeneration of the liver and spleen, tuberculosis of 
the lungs, and parenchymatous nephritis. 



454 



DISEASES OF CHILDREN 



Tuberculous peritonitis is comparatively rare in children under 
three years of age, but quite frequent in those over this age. The 
classical variety of tuberculous peritonitis is the chronic form. Oc- 
casionally, however, it may pursue a subacute, or even an acute 
course with chills, nausea, vomiting*, acute abdominal pain, and high 
fever, simulating acute perforative peritonitis of appendiceal origin. 
In the majority of instances the disease sets in insidiously with symp- 
toms of dyspepsia, anemia, evening rise of temperature, accelerated 
respiration and pulse, frequent attacks of colic and more or less pro- 




Fig. 110. — Tuberculous peritonitis in a baby fifteen months old ; she has fully 
recovered after laparotomy. The von Pirquet test was negative and the diagnosis 
was based chiefly upon the differential sign mentioned on page 155. 



nounced diarrhea. Very soon the characteristic symptoms of the dis- 
ease are in full bloom. The abdomen is distended and its wall often 
glistening and traversed by blue lines, the epigastric veins. The um- 
bilicus is either effaced or protuberant. The extremities are ema- 
ciated and contrast strongly with the gradually enlarging abdomen. 
Some portions of the abdomen are flat on percussion, eliciting the 
presence of fluid or nodular masses, other portions again are tympan- 



SPECIFIC COMMUNICABLE DISEASES 455 

itic, denoting that part of the abdominal enlargement is due to in- 
testinal gases. 

Palpation sometimes confirms the findings on percussion. Occa 
sionally hard, cord-like, painful masses and thickened omentum or 
adherent intestinal loops are found, of more rarely large tumors or 
encapsulated abscesses are detected. The latter if situated near the 
navel (periumbilical tuberculous abscess) may open and discharge 
through the navel. The abdominal enlargement may persist, or after 
disappearance of the fluid content and formation of fibrous adhesions 
the abdomen may retract, become tray-shaped, and remain so until 
exitus. 

If not arrested by therapeutic measures the disease usually runs a 
very protracted course — months or even years. Remissions are not 
rare, but sooner or later the symptoms return, sometimes in acute 
form; the patient wastes away, is troubled by hectic fever, sweats, 
diarrhea, hiccough, vomiting, dysuria, anuria, and edema of the lower 
extremities or general anasarca, until death finally relieves him of 
his agony. Fatal issue may occur also from intercurrent diseases, 
such as intestinal perforation, tuberculosis of the meninges or lungs. 

On the other hand, the prognosis is not as grave if treatment is 
instituted early, provided, of course, that the disease is limited to the 
peritoneum. 

Unfortunately in the early stage of the disease, the symptoms are 
not infrequently masked, and a positive diagnosis cannot be arrived 
at until the pathognomonic signs of the disease have made their ap- 
pearance, i. e., abdominal distention, circumscribed dulness, emaciation, 
diarrhea (diarrhea, emaciation and glandular swelling are often ab- 
sent), hectic fever, and swelling of the inguinal glands. Even then the 
peritonitis may be confounded with ascites, accompanying cirrhosis 
of the liver or valvular heart disease. In such cases the diagnosis may 
sometimes be settled by the tuberculin tests, by a bacteriologic exam- 
ination of aspirated abdominal fluid or by inoculation experiments. 
(See also "Chronic Abdominal Enlargement," p. 151.) 

Treatment. — As spontaneous cure is extremely rare and radical 
cures by laparotomy are quite frequent (about 50 per cent), the latter 
mode of treatment should be resorted to as soon as practicable. Some 
authors attribute the curative effect of laparotomy to the admission 
of atmospheric air to the abdominal cavity, others to hyperemia of the 
peritoneum produced by the operation in a manner similar to that em- 
ployed by Bier in the cure of tuberculosis of the extremities. Ex- 
cept abundance of sunshine, sojourn at the seashore or mountains and 



456 DISEASES OF CHILDREN 

plenty of wholesome food — whieh measures should be employed also 
in conjunction with an operation — all other medical procedures are 
only of temporary benefit. 

Intestinal Tuberculosis 

(Tabes Mesexterica) 

According* to Hess, the bovine type of tubercle bacilli is responsible 
for 60 per cent of these cases. The tuberculous lesions are usually 
found in the lowest portions of the ileum, ileocecal region and colon. 
It is manifested by a tuberculous infiltration of the solitary follicles 
and mucosa of the intestines, which gradually undergo softening and 
caseation and finally break down, leaving behind annular ulcers. Tu- 
berculous inflammation of the large intestine may produce so much 
swelling as to occlude the intestinal lumen. Sooner or later the inflam- 
mation extends to the mesenteric glands and the peritoneum. Occa- 
sionally the lungs and ether organs become involved. 

All these manifestations, however, are observed only at the autopsy. 
During life the symptoms are very obscure. Palpation may reveal en- 
larged mesenteric glands deep down in the abdomen, but more fre- 
quently owing to meteorism they escape observation, and even if pal- 
pable are not invariably tuberculous in nature. If, however, this symp- 
tom is associated with enlargement of the other glands of the body, stub- 
born diarrhea (greenish-gray in color, mixed with mucus, pus, and of- 
ten blood), emaciation and cachexia, sweats and hectic fever, the diag- 
nosis of intestinal tuberculosis is fairly certain. The diagnosis is ren- 
dered positive by the demonstration of tubercle bacilli in the stools. 
The tuberculin test and examination cf the sputum often prove decisive 
in doubtful cases; and complications, such as perforation of the intes- 
tines with consecutive peritonitis, settle the diagnosis beyond a doubt. 
Indeed, in the majority of instances the diagnosis cannot be made until 
these complications arise, a period at which therapeutic measures al- 
most invariably fail. At all events the prognosis is extremely grave. 

Cases of local tuberculosis detected early and treated energetically 
(chiefly surgically) may recover. 

Tuberculosis of the Genitourinary Tract 

Urogenital tuberculosis, especially tuberculosis of the kidneys, is 
comparatively common in children. It occurs either as a manifes- 
tation of general tuberculosis or as an independent disease. In 
the latter event it almost invariably begins in one kidney, and from 



SPECIFIC COMMUNICABLE DISEASES 457 

here it spreads to the bladder, and to the other kidney. In the be- 
ginning the affection is very apt to be overlooked, but, as the tubercu- 
lous process advances, the symptoms (pain in the region of the kidney 
and ureter, thickening of the ureter— as evinced by palpation with the 
finger in the rectum or vagina— irritability of the bladder, albumin- 
uria, pyuria, and often hematuria) become sufficiently characteristic 
as to demand careful repeated, bacteriologic examination of the urine 




Fig. 111. — Characteristic early tuber- Fig. 112. — A large tubercular ulcer be- 

cular infiltration, as seen through the low the orifice of the right ureter, 
cystoseope. (Leedham-Green.) | (Leedham-Green.) 




Fig. 113— Cystoscopic view of the base of the bladder in a case of tuberculosis 
of the left kidney (Wyatt). The opening of the right ureter is normal; the open- 
ing of the left ureter is seen to be gaping, the lips edematous and thickened, show- 
ing the presence of small miliary tubercles. 

for tubercle bacilli, and cystoscopic inspection of the bladder for tu- 
berculous lesions. Even in the early stage, systematic cystoscopic 
examination of the bladder will rarely fail to detect tuberculous nod- 
ules and ulceration about the opening of one ureter (Fig. 113). In 



458 DISEASES OF CHILDREN 

cases of long standing the lesions are often scattered throughout the 
bladder. As in tuberculosis of the other organs, the tuberculin test 
should always be employed to corroborate the diagnosis. Early recogni- 
tion of the condition and prompt surgical treatment are not rarely 
followed by permanent recovery. 

Scrofulosis 

(Tuberculosis of the Skin, Mucous Membranes and Glands) 

The tuberculous symptom-complex presently to be described should 
not be confounded with similar groups of symptoms which are tran- 
sient in character and generally due to strepto- and staphylococcus in- 
fection. Genuine scrofulosis attacks children with undermined consti- 
tutions who are poorly fed and cared for, forced to live in damp, dark 
and filthy dwellings, and who are exposed to tuberculous infection. 
Various skin eruptions, or injuries, exanthemata, decayed teeth, and 
diseased tonsils and adenoids, among others, serve as the portals of en- 
try to the tubercle bacilli. The immediate result of the tubercular infec- 
tion is hyperplasia, and the more remote effect, caseous degeneration of 
the parts primarily involved, and frequently secondary infection of the 
neighboring structures. 

Clinically, scrofulosis is characterized by simultaneous or successive 
involvement of the skin, mucous membranes and lymphatic glands; 
chronicity of its course, and a tendency toward slow spontaneous re- 
covery, or transition into general tuberculosis. 

The skin is the seat of a pustular eruption which resists ordinary 
local treatment, generally involves the subcutaneous tissue, and breaks 
down, forming slowly discharging abscesses or indolent ulcers. It is 
most frequently situated upon the back and nates, but is found also 
upon the scalp and face — probably carried from one part to the other 
by scratching by means of infected fingers. 

Scrofulosis of the mucous membranes is manifested chiefly by naso- 
pharyngitis. From the nasopharynx the inflammatory process may 
spread to the ears, eyes, larynx and oral cavity. 

The nasal mucous membrane is red and swollen and discharges a 
seropurulent secretion which forms yellowish-green crusts within and 
around the nares, producing snuffling respiration and excoriation of 
the upper lip. A similar acrid discharge is usually observed from the 
ears (bilateral otorrhea). Both the nasal and aural discharges may be- 
come purulent and fetid ; in the first instance, by extension of the inflam- 
mation from the nasal mucous membrane to the cartilage, periosteum 



SPECIFIC COMMUNICABLE DISEASES 



459 



and even nasal bones (sometimes marked nasal deformity) ; in the sec- 
ond instance, by implication of the middle ear and eventually the ossi- 
cles, or petrous portions of the temporal bones. 

Scrofulosis of the eyes, the so-called strumous ophthalmia, usually 
begins with redness and swelling of the palpebral mucous membrane, 
and in the majority of cases is soon followed by involvement of the 
cornea, in the form of phlyctenular keratitis, with strong lacrimation, 
pain, and photophobia. The phlyctenule are very slow in healing, and 
show a great tendency to leave behind corneal opacities. Blepharo- 
adenitis, madarosis and permanent thickening of the edges of the lids are 
quite common accompaniments. 




Fig. 114. — Tuberculous axillary lymphadenitis. 



The lymphatic glands are affected early or late — secondary to the in- 
flammation of the skin and mucous membranes. Except their wide 
distribution, the glandular swellings present nothing characteristic in 
the beginning, but as the disease progresses they show a marked ten- 
dency to undergo caseation and suppuration. Furthermore, after evac- 
uation of the pus which usually contains tubercle bacilli, they rarely 
cicatrize, but, on the contrary, continue as pus-discharging fistulas 
or indolent ulcers. 



460 DISEASES OF CHILDREN 

The course of the disease depends greatly upon the vitality of the 
patient and the mode of treatment. It is always chronic. Children re- 
moved from the obnoxious surrounding's frequently recover completely. 
In those not properly cared for, the tuberculous process is very prone to 
spread to the osseous system and to the internal organs. Spina ven- 
tosa, osteomyelitis and spondylitis form frequent sequelas. (For de- 
tails of these affections the reader is referred to the chapter on "Tu- 
berculosis of the Bones," p. 761.) The internal organs, especially the 
liver, spleen and lungs, may be implicated singly or collectively, in which 
event the prognosis of course, is extremely bad. 

Characteristic as the symptom complex of scrofulosis seems to be, 
errors of diagnosis are nevertheless very apt to be made. The perplex- 
ity is often great in the differentiation between scrofula and inherited 
syphilis, both of which diseases have many symptoms in common. In 
all such doubtful cases, it is wise, on the one hand to employ the tu- 
berculin reaction, and examine the aural and nasal secretions as well 
as the pus from scrofulous abscesses for tubercle bacilli, and, on the 
other, to administer mercury and to look for the Spirochete pallida, 
One should not be too hasty in pronouncing a case as scrofulosis be- 
cause of the so-called "torpid habitus" of the patient (pale, flabby, 
puffed face, thick nose, swollen and excoriated upper lip, redness and 
thickening* of the lids), or the presence of adenoids or glandular swell- 
ing. These symptoms can and often do exist independently of tuber- 
culosis, and, as already suggested, may be due to infection by other mi- 
croorganisms. 

Treatment. — Scrofula, like other forms of tuberculosis, demands 
early and energetic treatment. The patient should be removed from the 
obnoxious influences, should be well nourished and kept outdoors the 
greater part of the day. (See p. 449.) Under suitable conditions he 
should also be given the benefit of tuberculin therapy (q. v.). Internally 
we should administer, for several months in succession, moderately large 
doses of the syrup of the iodide of iron and syrup of the hypophosphites, 
as well as cod liver oil or similar alterative tonics. The local treat- 
ment, which is of very great importance, essentially consists of thorough 
bodily cleanliness (daily bath with sea salt, antiseptic dressings in open 
wounds, etc.) ; removal of diseased foci such as tonsils and adenoids, de- 
cayed teeth, caseated glands, etc., and evacuation of pus wherever 
found. Individual complications should be vigorously combated accord- 
ing to indications. (See bone tuberculosis, otitis, eczema, etc.) As the 
external lesions are probably carried from place to place by means of 
the fingers, open wounds (vaccination wounds!) should be thoroughly 



SPECIFIC COMMUNICABLE DISEASES 



4G1 



protected and the patient's finger nails clipped and kept scrupulously 
clean to prevent scratching the diseased parts of the body and direct 
infection of its healthy portions. 



Ii Syr. Ferri Iodidi 3 iv 


15.00 


Syr. Calcii et Sodii 




Hypophospliitum q. s. ad f § ii 
M. 
S. — One teaspoonful three times a day for 


60.00 


a child 


three vears old. 





TUBERCULOSIS OF THE BONES AND JOINTS 

Tubercular Osteomyelitis and Arthritis 

The grouping together of tuberculous bone and joint diseases is 
intended to emphasize their correlation. The favorite seat of bone 
tuberculosis is usually in the epiphyses, the joint becoming involved 




Fig. 115. — Tuberculosis of elbow joint in a boy eighteen months old. Xote dis- 
charging sinus. 



462 DISEASES OF CHILDREN 

secondarily by extension of the inflammatory process to the syno- 
vial structures. Occasionally, the joint is affected primarily. 

The immediate cause of the disease is the tubercle bacillus which 
invades the medullary tissue, the bone proper, or the articular struc- 
tures, either from within — from a florid or latent tuberculous focus 
elsewhere — or from without, as a result of traumatism. An inherited 
predisposition and impaired nutrition from various causes favors the 
development of tuberculous disease. 

Osseous, as well as articular, tuberculosis is essentially a chronic in- 
flammatory process, free from the violent symptoms which are char- 
acteristic of acute, nontuberculous osteomyelitis. Extensive lesions 
may exist for weeks and months with apparently perfect health. Fever 
is usually absent in the beginning and only slight — in the evening — 
at a later stage of the disease. As the tuberculous process advances, 
progressive anemia and emaciation make their appearance, but are 
not pathognomonic of the affection. The local symptoms also are 
very vague at first. Hence the reason why local tuberculous disease 
is frequently overlooked until, as will presently be shown, deformity 
and loss of function have occurred, which vary greatly in extent and 
severity with the seat of the lesions and the mode of treatment. 

Tuberculosis of the Vertebral Column 

(Spondylitis. Pott's Disease) 

This tuberculous process usually begins in or near the vertebral body, 
and if not arrested, gradually extends to the contiguous structures, in- 
cluding the spinal cord. 

It is manifested by an ulcerative and often suppurative destruction 
of the bone, with metastatic (gravitation) abscesses in distant locations, 
e. g., retropharyngeal abscess, in cervical spondylitis ; psoas abscess, in 
lower dorsal and lumbar disease. Furthermore, with softening and 
crumbling of the vertebral bodies, the spinal column, as it were, top- 
ples over, usually backward, producing a deformity known as kyphosis, 
gibbus or Pott's hump. The condition is gradually further aggravated 
by compensatory spinal deformities (especially lordosis) and a group 
of other distressing pressure symptoms, soon to be related, which if not 
arrested throw the unfortunate creature in an abyss of everlasting 
misery. 

This process, fortunately, is very slow in development, affording am- 
ple time — from three to ten years — to arrest and mend its ravages and 
ample warnings to the patient to seek relief. We may frequently dif- 
ferentiate four stages in the progress of the affection: (1) The stage 



SPECIFIC COMMUNICABLE DISEASES 



463 



of onset, where the symptoms are very vague and inconstant. The 
child shows a disinclination to play, refuses to walk, or tires easily when 
he does walk. He complains of pain in different parts of the body, fol- 
lowing the distribution of the spinal nerves, the pain being often so 
severe, especially at night, that it wakes the child from his sleep with 
a sudden start — "starting pain" ; (2) the stage of fixation of the spinal 
column; (3) the stage of characteristic deformity; and (4) the stage of 
suppuration and pressure paralysis. The disease does not always pro- 
gress to the last stages. In some instances, after two or three years' 
course, either through treatment or spontaneously, solidification of the 




Fig. 116. — Pott's disease (Langerhans and Brooks, F. A. Davis Co.). Kyphosis 
of dorsal vertebras, the result of caseous tuberculous periostitis and osteomyelitis. 
Destruction of three thoracic vertebra?. Two-thirds natural size. 



diseased vertebras — a relative cure — occurs. Relapses, however, are not 
infrequent. Pressure paralysis (see "Myelitis," p. 656) is especially 
common in disease of the lower cervical and upper dorsal regions. 

The focal symptoms vary with the seat and extent of the lesion. In 
cervical spondylitis the patient, if old enough, complains of neuralgic 
pain in the head and upper portion of the neck. Very young chil- 
dren indicate the presence of pain by a suffering and an anxious expres- 
sion of the face, by refusal of food and crying on handling. The head 
is stiff, tipped backward or laterally (torticollis-like), and, when the 



464 DISEASES OF CHILDREN 

child moves, he is often seen to support his head with the hands. At 
a later stage of the disease, there are often disturbances of deglutition 
and phonation, not rarely due to tubercular retropharyngeal abscess. If 
the uppermost cervical vertebra? are diseased, there is danger of ante- 
rior displacement of the head between the atlas and axis, more rarely 
between the occiput and atlas, and death from pressure upon the cord. 
The permanent deformity in cervical spondylitis usually consists of 





Fig. 117. Fig. 118. 

Fig. 117. — Eigidity of neck associated with ' ' cervical ribs. ' ' For over two years 
patient was treated by eminent orthopedic surgeons for cervical spondylitis until a 
roentgenogram revealed the error in the diagnosis. 

Fig. 118.- — Same case as in Fig. 117 showing peculiar attitude of head which led 
to the erroneous diagnosis. 

thickening and broadening of the neck, and sinking of the head upon 
the shoulders. 

In dorsal spondylitis the distribution of the pain differs somewhat 
with the particular part of the spine involved. If the upper dorsal ver- 
tebra? are affected, the pain resembles that of intercostal neuralgia, and 
increases on coughing, sneezing, laughing, etc.. while in spondylitis of 



SPECIFIC COMMUNICABLE DISEASES 



465 



the lower dorsal vertebrae, the most frequent seat of the disease, the 
pain radiates to the lower extremities. In disease of this region, fur- 
thermore, the upper part of the body deviates to the side, one shoulder 
is elevated and the trunk bent to the opposite side — a state of scoliosis ; 
at the same time the vertebral column is kept rigid, every movement 
carefully avoided, and, in walking, short rigid steps are taken, the pa- 
tient timidly balancing the superincumbent weight of the body by 
firmly supporting the spine with the hands. If urged to pick up some- 
thing from the floor, the child stoops by strongly flexing the knee- 




Fig. 119. — Advanced dorsal spondylitis with gibbus. 



and hip-joints, while holding the vertebral column perfectly rigid, and 
raises himself by resting the hands upon the thighs, and then, with 
alternating supporting movements along the thighs and trunk, elevates 
the body and lastly extends the legs. If bending of the spinal column is 
attempted, motion occurs only in the healthy sections, the diseased por- 
tions remaining firmly fixed. The ultimate spinal deformity consists of 
kyphosis, kyphoscoliosis and lordosis. 

In him oar disease the patient complains of pain in sitting, and refers 
it also to the lowest portion of the abdomen and the legs. The physical 



466 DISEASES OF CHILDREN 

signs are essentially the same as in spondylitis of the lower dorsals, 
except that the deformity occurs at a later period and is not as pro- 
nounced. On the other hand, there is a greater tendency toward the 
formation of psoas abscess — a tumor deep in the iliac fossa or at the 
anterior surface of the thigh, lameness and flexion of one thigh. 

Careful attention to the aforementioned physical signs rarely fails 
to disclose the presence of vertebral caries, even at an early stage of 
the disease. Cervical spondylitis may be mistaken for torticollis (sud- 
den onset, pain and unilateral contracture more pronounced ; early re- 
sponse to anodynes and antirheumatics, etc.) ; for cervical rib (re- 
vealed by x-ray) ; nontaberculous retropharyngeal abscess (immediate 
relief on puncture). Dorsal and lumbar spondylitis may be confounded 
with rachitic curvature (rounded in rickets; angular in spondylitis: 
rachitic kyphosis is reducible by placing the child upon the abdomen 
and overextending the thighs ; absence of characteristic gait and mode 
of stooping). Right iliac psoas abscess often resembles appendicitis 
(onset sudden or recurrent, rigidity of the abdominal muscles, absence 
of spinal disease). Psoas abscess differs from hip-joint disease, by the 
hip-joint being fixed in the latter affection ; and from hernia, by the latter 
being reducible in recumbent posture. 

In view of the comparatively slow course of the disease in the major- 
ity of cases, the prognosis as to life is good, and as to permanent de- 
formity fair, provided the treatment is begun early and persisted in. 
The prognosis is bad in cases presenting abscesses, fistulas, and -pressure 
paralysis. Even here surprisingly good results are often obtained un- 
der suitable treatment. 

Treatment. — The treatment is principally orthopedic and surgical — 
fixation of the spine by a plaster of Paris or (in milder cases) cellu- 
loid jacket, rest in bed to unburden the spinal column, and evacua- 
tion of large collections of pus {e.g., retropharyngeal or psoas ab- 
scesses). The F. M. Albee method of bone-grafting has proved emi- 
nently successful in a great many cases. Good hygiene, outdoor air, 
plenty of nutritious food, and iron, hypophosphites and cod liver oil 
will facilitate a cure. 

Morbus Coxarius 

(Hip- Joint Disease. Coxitis Tuberculosa. Articular Osteitis of the 

Hip) 

The pathologic process of this tuberculous affection is usually de- 
scribed as consisting of three stages (1) The stage of ostitis, as a rule, 
involving the femoral head, less frequently the acetabulum; (2) the 



SPECIFIC COMMUNICABLE DISEASES 



467 



stage of arthritis or suppuration, in which all the joint structures are 
implicated; and (3) the stage of disintegration and absorption of the 
head and sometimes the neck of the femur and the upper and back part 
of the acetabulum, with "wandering" of the head of the femur upward 
and backward upon the dorsum ilii. 

Simultaneously with the onset of the first stage of the pathologic 
process, or sometimes at a later period, the child begins to limp and to 




Fig. 120. — Tuberculous coxitis, advanced stage. 

complain of pain in the knee- or hip-joint or both. As a rule, the limp 
at first is intermittent in character, more marked either in the morning 
or in the evening, but as the inflammation progresses, it becomes con- 
stant and quite pronounced, the leg at the same time being held very 
rigid. With the occurrence of articular exudation, the leg assumes a 
pathognomonic position of flexion, abduction and eversion, and the pa- 
tient in order to bring the foot to the ground depresses the pelvis on 
the affected side, this giving rise to slight — apparent — lengthening of 



468 



DISEASES OF CHILDREN 



the limb. With destruction of the joint and the articular bony struc- 
tures, the hip-joint becomes further flexed, inverted and adducted. To 
overcome the uselessness of the limb in this position the patient ele- 
vates the pelvis on the affected side, and to counteract the — apparent — 
shortening, he steps on the ball of the foot. Later real shortening en- 
sues, owing to the wandering of the femoral head upward and back- 
ward, and the firm contraction and atrophy of the muscles. 




Fig. 121. — Early stage of hip-joint disease. 



In consequence of the pelvic obliquity, in the upright posture, the pa- 
tient assumes a position of compensatory scoliosis and lordosis. In 
the recumbent posture, with the limbs brought down parallel to each 
other, there is always compensatory lordosis of the lumbar region. This 
lordosis disappears on flexing the affected limb at the hip to an angle 
at which it is held flexed by the contracted muscles. 

The intensity of the pain varies. It is usually worse after manipu- 
lation and fatigue, and at night. It may awaken the child from his 



SPECIFIC COMMUNICABLE DISEASES 469 

sound sleep with a cry ("starting pain"). The pain not rarely is re- 
ferred to the knee, or to other parts supplied by the obturator nerve, 
e. g., the inner side of the thigh. Hence the importance of always ex- 
amining the hip-joint in such cases. 

In addition to the pain, the limp and false position, we may find, at a 
late stage of the disease, involvement of the inguinal glands, with or 
without suppuration and perforation; enlargement — "white swelling" 
— of the hip ; flattening of the gluteal region and effacement of one glu- 
teal fold; multiple abscesses and fistulse at various points of the hip or 
thigh, especially at the tensor fasciae lataa, and irregular temperature, es- 
pecially during the stage of suppuration. 

Cases presenting the aforementioned typical symptoms are recogniza- 
ble at a glance. Indeed, at this very late stage of the disease, it is al- 
most immaterial whether a correct diagnosis is made or not, since a fa- 
tal issue from exhaustion, amyloid degeneration and general tubercu- 




Fig. 122. — Hip-joint disease. Note compensatory lordosis on full extension of af- 
fected limb. 

losis is all that can be expected, particularly in children with a tubercu- 
lous diathesis. The center of the physician's interest, therefore, should 
rest upon the diagnosis of incipient coxitis, which, if properly treated, 
offers good prospect of recovery. A history of slight trauma ; occasional 
dragging of the leg or limping ; pain in the hip- or knee-joint ; disin- 
clination to play and undue fatigue after slight exertion; restless sleep 
and "starting pain," all point to coxitis and demand very careful and 
repeated examinations of the hip-joint. The diagnosis is greatly facil- 
itated and, in the majority of instances, rendered positive by the pres- 
ence of pain on pressure against the trochanter, or against the ace- 
tabulum (by digital rectal examination), and by von Pirquet's tuber- 
culin test. Advanced coxitis can readily be diagnosed by the afore- 
mentioned faulty attitude of the patient, in recumbency, standing, or 
walking. In doubtful cases, an x-ray examination (by an experienced 



470 DISEASES OF CHILDREN 

radiographer) is decisive. The latter procedure is especially useful in 
differentiating coxitis from: Injury to the hip (disability follows imme- 
diately after the accident; local signs of injury, e.g., ecchymosis, etc.) ; 
coxa vara (x-ray shows downward inflexion of the neck of the femur; 
adduction and extension of the limb are usually possible) ; congenital 
dislocation of the hip (history of lameness from birth; absence of in- 
flammatory signs or limitation of motion) ; osteomyelitis with separa- 
tion of the epiphyses (very violent course) ; rheumatism (yields to the 
salicylates; no bone lesion) ; spondylitis of the lumbar region (distinct 
symptoms of spondylitis; hip-joint free); hysteria (absence of joint 
trouble, best proved under anesthesia, and by means of x-ray) ; peri- 
osteal sarcoma (Fig. 476) of the trochanter (the swelling rapidly in- 
creases in size; marked dilatation of the superficial veins). 

Treatment. — The treatment consists of reduction of existing deform- 
ity, either gradually (by weight and pulley, while the patient is in bed) 
or forcibly (under anesthesia); disencumbrance of the hip-joint of the 
body weight, at first by rest in bed (bed extension apparatus) and later 
by means of an extension-walking apparatus (to enable the patient 
to enjoy fresh air) and, finally, fixation of the hip- joint by a plaster- 
of-Paris spica or a fixation apparatus. Fixation of the joint as well 
as extension should be continued for some time after apparent recovery. 
Constitutional treatment. Massage to prevent atrophy of the muscles 
and stiffness of the healthy joints. 

Knee-Joint Disease 

(Tuberculosis of the Knee- Joint, "White Swelling) 

The pathologic process of tuberculosis of the knee-joint resembles 
that of the hip. It may begin in the synovial membrane or in the articu- 
lar ends of the osseous structures. The clinical symptoms are practi- 
cally the same, whether the synovialis has been affected primarily or 
secondarily. They consist of fusiform swelling, local tenderness, atro- 
phy of the thigh and calf muscles, flexion and slight outward rotation 
of the knee, and later abscess formation (extra- or intra-articular). 
During the suppurative stage, less frequently in the absence of sup- 
puration, there are more or less constitutional symptoms, such as ano- 
rexia, anemia, emaciation and irregular fever. The latter is quite high 
in the presence of secondary infection. 

The tuberculous process pursues a rather slow course. Not rarely it 
is interrupted by prolonged remissions. Exacerbations are often in- 
duced by local trauma or intercurrent acute diseases, sometimes after 



SPECIFIC COMMUNICABLE DISEASES 



471 



an "apparent" cure has been established. The prognosis, as a whole, 
however, is favorable, if treatment is begun early and properly. The 
very rarely occurring spontaneous recovery should not be depended 
upon. 

Treatment. — Within recent years the treatment of tuberculosis of 
the knee-joint, as veil as that of the other smaller joints, has been en- 




Fig. 123. — Tuberculosis of the knee in a thirteen month old infant who a few months 
later succumbed to tuberculous pyothorax. 



tirely revolutionized. Instead of resorting to immobilization, resec- 
tion and permanent fixation, Bier's method of passive hyperemia has 
become the treatment of choice, since it not only aids nature in the 
healing of the tuberculous process but tends also to restore the nor- 
mal functions of the affected joint. The mode of procedure is very 



472 DISEASES OF CHILDREN 

simple. A soft rubber bandage about 2 inches in width is applied gently 
and evenly around the extremity (over a light flannel bandage), at 
some distance above the lesion, e. g., at the middle or upper third of the 
femur in tuberculosis of the knee-joint, and left in place for an hour 
or two, once or twice a day. If the bandage is properly applied, it gives 
rise to no pain, or interruption of the pulse. The extremity below the 
bandage soon swells slightly, and assumes a bluish-red color, but re- 
mains warm. The favorable results obtained from this mode of treat- 
ment of tuberculous joints are rather slow in coming (from three to 
nine months), but in uncomplicated cases well worth waiting for. Com- 
plications arising should be treated symptomatically. Thus cold ab- 
scesses call for free incisions and evacuation (may be enhanced by 
suction with Bier 's cup ) of the necrosed tissue ; large exudations should 
be treated by aspiration and injection of iodoform emulsion or bis- 
muth paste* and the general health should be improved by outdoor 
fresh air, nutritious food, tonics (iron and cod liver oil), massage and 
hydrotherapy. (For differential diagnosis, see ''Arthritis," p. 418.) 
Tuberculin therapy (q. v.) is of undoubted value in the early stage of 
the affection. 

Spina Ventosa 

(Tuberculosis of the Metacarpals and Phalanges, Tuberculous 

Dactylitis) 

This disease most frequently affects the first phalanx of the index 
finger, but may occasionally be found simultaneously in several 
phalanges or metacarpals of the same hand. The osseous tissue is grad- 
ually destroyed, and while this is going on, here and there new bone 
tissue is gradually formed under the periosteum. In consequence of 
the latter process, the finger becomes fusiform, as if the bone had been 
"blown up" (see Fig. 124). As the inflammatory process is very slow 
and painless, it, as a rule, takes several months before the characteristic 
appearance is developed. At a later stage of the disease, there is cir- 
cumscribed redness, fluctuation, impairment of function of the tendons 
and spontaneous rupture of the suppurating focus with very tedious 
discharge of the contents. 

Tuberculous dactylitis may be mistaken for a congenitalor acquired 
syphilitic lesion. The history of syphilis, the presence of other syphi- 
litic symptoms, the greater tendency of syphilitic dactylitis to be mul- 



*Emil G. Beck's Method: Bismuth subnitrate 33 per cent, petrolatum (yellow) 67 per cent. 
The paste is injected slowly by means of a strong glass syringe with a conical pointed nozzle 
similar in shape to that of the ordinary urethral syringe, but much larger. Its prolonged use 
may give rise to bismuth poisoning! 



SPECIFIC COMMUNICABLE DISEASES 



473 



tiple and symmetrical, and the ready response to antisyphilitic treat- 
ment usually suffice to clear up the diagnosis. A negative Wasser- 
mann reaction and a positive von Pirqnet tuberculin test, and the coin- 
cidence of tuberculous lesions elsewhere, strongly point to tuberculosis. 




Fig. 12t. — Spina ventosa. 

Early constitutional treatment including tuberculin (q.v.), and pas- 
sive hyperemia (see p. 472) are very efficient curative measures. Con- 
servative surgery (evacuation of pus and sequestra and injection of 
bismuth paste) is indicated in neglected cases. In these recovery is 
slow, usually with permanent deformity. 



Nontuberculous Osteomyelitis 

(Osteitis; Periostitis) 

The term osteomyelitis refers chiefly to inflammation of the marrow 
of the bone, but includes also the morbidity of the bony matrix and 
periosteum, which at one period or another participates in the destruc- 
tive processes. 

Osteomyelitis is exceedingly common in children below the age of 
puberty — before completion of ossification of the epiphyses and dia- 
physes — since the anatomic peculiarities of the circulation in growing 
bones particularly favor its development on slight provocation. The 
affection is observed in two forms: nontuberculous and tuberculous 
(see p. 461). Xontuberculous osteomyelitis most frequently affects 
the long bones of the lower extremity (femur and tibia), less often the 



474 DISEASES OF CHILDREN 

other long bones, and exceptionally the short bones of the body. In 
most instances it is the result of infection of the medullary tissue by 
pus microbes, especially the staphylococcus and streptococcus, which 
enter the blood from suppurating wounds of the skin (pustular erup- 
tion!) or from pathologic foci in the respiratory or alimentary tract. 
As predisposing and contributory causes, we may mention the various 
contagious and infectious diseases, such as typhoid, scarlatina, measles, 
pneumonia, sepsis neonatorum, etc., all of which being instrumental in 
lowering the vitality and resistance of the patient. 

Infection of the medullary tissue once established, the pathologic 
process is very acute and violent. If left alone, the inflammatory proc- 
ess rapidly goes on to suppuration, leading to loosening of the perios- 
teum and bone necrosis and separation of the diaphysis from its epiphy- 
sis. If the patient survives and the inflammatory process subsides, 
there is a separation of the dead bone (sequestrum) from the living. 
Unless removed, the sequestrum may remain an everlasting source of 
irritation and suppuration. 

The osteomyelitic process is usually ushered in by a chill, rapid rise 
of temperature and pulse and other symptoms which usually accom- 
pany acute suppurative affections. Before the appearance of the local 
symptoms, the disease is very apt to be mistaken for a pyemic or ty- 
phoidal condition; and in infants unable to indicate the presence of lo- 
cal pain, osteomyelitis may end fatally before a correct diagnosis has 
been arrived at. Hence, the importance of a careful examination of 
the bony system in all febrile affections with indefinite source. 

In the newborn the onset may be insidious. There may be signs of 
omphalitis or the umbilicus may already be healed. For some obscure 
reason the infant may begin to cry, especially when handled. On care- 
ful examination it is found that the baby refuses to move the affected 
extremity (see Fig. 55). 

The local symptoms of osteomyelitis are pain, tenderness, swelling, 
redness, synovitis, epiphyseolysis. and loss of function. 

The pain is excruciating, boring or throbbing, worse at night, and 
increases in intensity as the exudation becomes more abundant. Young 
children are rarely capable of locating the exact seat of the pain, but 
usually refer to the entire affected limb. As a rule, the pain disap- 
pears suddenly with the escape of the inflammatory products from the 
interior to the exterior of the bone. 

Tenderness on pressure can be detected early, and is most severe 
where the inflammation has approached nearest the surface of the bone. 



SPECIFIC COMMUNICABLE DISEASES 475 

Wlieu the disease is located deeply in the medulla, tenderness can be 
elicited by percussion. 

Swelling and redness are not discernible until the inflammation has 
reached the periosteum. Thrombophlebitis and edema, however, are 
often early symptoms. 

Synovitis is the rule where the disease affects the epiphysis as well 
as the end of the diaphysis. The intraarticular effusion is at first ser- 
ous, the result of vascular disturbance, but as the suppurative process 
in the bone advances, the effusion becomes purulent by direct exten- 
sion of the infection. The character of the effusion can readily be de- 
termined by exploratory puncture. 

Epiphyseolysis, or separation of an epiphysis from the diaphysis, is 
a late symptom, or rather a complication. It may be recognized by 
soft crepitation between the separated parts, false point of mobility and 
displacement — signs of fracture. 

Loss of function of the limb is invariably present, and as the dis- 
ease advances there are marked contractures. The patient instinctively 
assumes such postures as will best relax the muscles and ligaments con- 
nected with the affected area, and thus prevent painful tension. 

These symptoms, if closely kept in view, will generally avoid errors 
in the diagnosis. Typhoid fever can readily be excluded even before 
the development of local symptoms by the presence of marked leuco- 
cytosis in osteomyelitis. (For differential points between osteomyelitis 
and arthritides, see p. 418.) In eases of doubt a roentgenogram will al- 
most invariably settle the diagnosis. 

Treatment. — As previously indicated, the course of the disease va- 
ries with the degree of infection and the aggressiveness of the treat- 
ment. Early operative interference is usually followed by recovery 
in the great majority of cases. In some cases the infection is ex- 
tremely violent and death occurs within the first thirty-six hours, 
before or notwithstanding that a diagnosis had been made and the 
appropriate therapeutic measures employed. The great danger in 
osteomyelitis is the tendency to venous and arterial thrombosis with 
secondary embolism and abscesses in different parts of the body, es- 
pecially in the lungs, heart and kidneys. 

With subsidence of the acute symptoms, the osteomyelitic process 
is not always at an end. Transition into chronic osteomyelitis is not 
uncommon. (For details, see a treatise on surgery.) Suppurating 
sinuses leading down to the infected sequestra may indefinitely persist, 
and, with occasional improvement, continue to undermine the vitality 
of the patient. Amyloid disease of various viscera (liver!) may form 
a sequel of prolonged suppuration. 



476 



DISEASES OF CHILDREN 

Osteosarcoma 



Next to the kidneys (see p. 582) the osseous structures, and more 
particularly the long bones, form the most frequent seat of sarcoma in 
children. The sarcomas may be of central or peripheral origin. The 
periosteal variety is usually more rapid in growth and more apt to in- 




Fig. 125. — Osteosarcoma of the head and upper third of shaft of humerus in a boy 
ten years old. Note also early metastasis in the lungs. 

volve the bone some distance from the joint. The etiology is still ob- 
scure. In the majority of instances we can elicit a history of trauma- 
tism at the seat of the tumor or its immediate vicinity. 

In the early stages the affection may be mistaken for osseous tuber- 
culosis, syphilis, or chronic periostitis. In tuberculosis the swelling 



SPECIFIC COMMUNICABLE DISEASES 



477 




Fig. 126. — Enehondroma of upper third of humerus iu a child eleven years old. 



is more gradual in its development and most frequently attacks the 
joints. In syphilitic growths we usually find other signs of syphilis 
and a positive AVassermann reaction. Chronic or subacute periostitis 
with marked thickening of the periosteum and only a small amount of 
pus can readily be distinguished from osteosarcoma by a careful 



478 



DISEASES OF CHILDREN 




Fig. 127. — Bone cyst in shaft of humerus causing fracture in a ehilct six years old. 



Roentgen-ray examination, which should invariably be resorted to in 
cases of doubt. Of the benign neoplasms chondroma is most likely to 
simulate sarcoma, but chondroma is much slower in growth and un- 
accompanied by metastases — just the opposite of what is observed in 
sarcoma. In one case under our observation (Fig. 125) sarcomatous foci 
in the lungs were noted six weeks after the earliest signs of the tumor 



SPECIFIC COMMUNICABLE DISEASES 



479 



in the humerus. Constitutional symptoms usually set in late in the 
course of the disease — hence the reason why the relatives of the little 
patients are loath to accept the physician's advice regarding early 
radical therapeutic measures, and hence also the extraordinarily high 
mortality. 




Pig. 128. — Sarcoma of the- left femur in a girl eight years old. 

Treatment. — Where the diagnosis is made very early, i. e., before there 
are any evidences of metastases, amputation of the affected limb, as high 
as possible above the seat of the lesion, may save the patient 's life. The 
views on the results of radium treatment are too conflicting to take any 
chances on the postponement of the radical operation while awaiting the 
doubtful outcome of the radium treatment. All other methods of treat- 
ment thus far recommended are practically futile. 



Scoliosis 

(Lateral Curvature of the Spine) 

In contrast to the aforementioned tuberculous deformity (spondy- 
litis), scoliosis is not tuberculous in nature. As a rule, it is habitual, 
or static, the result of unequal (one-side) compression of the inter- 
vertebral cartilages, favored by atony of the muscles and ligaments 
and weakness of the bones. It is most frequently observed in school 
children, especially girls, and is generally ascribed to faulty posture 
while sitting at the school desk, etc., and to the habitual carrying of 
heavy books with one arm. I firmly believe that a great niairy cases of 
so-called habitual lateral spinal curvatures originate during early in- 



480 



DISEASES OF CHILDREN 



fancy in connection with rachitis (q.v.), arc generally overlooked while 
the deformity is slight, and are detected later, at a time when the de- 
formity does and would gradually get worse, whether or not the child 
goes to school. Of course, this view does not preclude the fact that 
faulty posture and encumbrance of one-half of the body hasten to ag- 
gravate the curvature. Less frequent causes are obliquity of the pelvis 
{e.g., shortening of one lower extremity from birth or postnatal dis- 
ease); unilateral paralysis (e.g., poliomyelitis, progressive muscular 
atrophy) ; unilateral immobility of the thorax (e.g., protracted exten- 
sive pleuritic effusion or adhesions) ; and unilateral sinking of the 




Fig. 129. — Lateral spinal curvature; second degree. 

thorax from traumatism or operations (e. g., multiple fractures of ribs, 
resection of ribs in pyothorax). Very rarely scoliosis is congenital in 
nature, when, as a rule, it is associated with other congenital malforma- 
tions. 

Scoliosis is manifested first by elevation of one shoulder, and later 
by prominence of one hip and scapula on the same side and gradually 
increasing convexity of the spinal column and side. With further prog- 
ress of the deformity, the spinal column presents two curves, in the 



SPECIFIC COMMUNICABLE DISEASES 481 

shape of the letter S — the primary curve, which is usually in the dorsal 
region, and the secondary or compensatory curve, usually in the lumbar 
region. Bad cases are occasionally complicated also by lordosis, de- 
formity of the thorax and displacement of the heart and lungs, but 
are otherwise free from constitutional symptoms. It may here be noted 
that marked lordosis has been found to be a cause of orthotic albumi- 
nuria (q. v.) 




Fig. 130. — Lateral spinal curvature, S-shaped scoliosis. 

Treatment. — Fortunately, nowadays, with the greater attention be- 
ing paid to the general health of children, these dreadful deformities 
are very rarely encountered. Many cases come under the care of the 
physician in the first stage of the disease which ordinarily yields to 
massage, calisthenics, fresh air, ample nutrition, general medicinal 
tonics, and, above all, removal of etiologic factors. Severer forms of sco- 
liosis are often corrected by a plaster-of -Paris or celluloid corset — worn 
continuously for several months, and followed bv massage and exercise to 



482 DISEASES OF CHILDREN 

strengthen the weak muscles. Fixed scoliosis can at best only be impeded 
in its further progress, but the damage done is frequently irrepara- 
ble. Hence, the importance of early and energetic treatment, and 
particularly of prophylactic measures, which are especially effective 
in habitual scoliosis. Here the school physician and teacher are 
offered mairy opportunities to merit the gratitude of the community. 

Syphilis Hereditaria S. Congenita 

(Syphilis Embryonalis or Fetalis, Syphilis Neonatorum, Syphilis 

Hereditaria Tarda) 

Congenital syphilis is due to a specific microorganism, the Spirochete 
pallida, which is transmitted to the embryo or fetus either through the 
syphilitic semen (ex patre), ovule (ex matre), or maternal blood (at any 
time during pregnancy). 

The great majority of syphilitic embryos or fetuses are aborted. The 
few that survive may pass through the syphilitic process in utero (syph- 
ilis embryonalis s. fetalis), or may maintain a good state of health dur- 
ing intrauterine life, be born in apparently perfect health, and develop 
the syphilitic manifestations soon after birth (syphilis neonatorum), or 
not until several years after (syphilis hereditaria tarda). 

Syphilis Embryonalis S. Fetalis 

The few babies who survive the syphilitic onslaught during intra- 
uterine life and are born at or near full term present a ghastly sight. 
They are shriveled and shrunken, emaciated and disfigured, with 
barely a spark of life in them. They are often asphyxiated and usu- 
ally die soon after birth. Postmortem examination may reveal pro- 
nounced pathologic changes in the lungs (fatty degeneration of the 
pulmonary alveoli — " pneumonia alba") ; in the liver (interstitial 
hepatitis) ; in the spleen and pancreas (induration and gummatous 
deposit) ; in the kidneys and suprarenal glands (perivascular infiltra- 
tion and anemia necrosis) ; in the thymus gland (cystic degeneration 
and abscess formation) ; and in the osseous system (epiphyseal osteo- 
chondritis after multiple fractures). The skin affection consists 
chiefly of "pemphigus syphiliticus," a bullous eruption on a dusky 
red, slightly elevated base, with a sanguinopurulent content. It is 
usually localized on the palms of the hands and soles of the feet. 
Owing to extreme tenderness of the body (syphilitic myositis'?) the 
infant is very restless, and cries pitifully when handled. 



SPECIFIC COMMUNICABLE DISEASES 



483 




Fig.. 131. — Congenital syphilis, baby three weeks old. oSTote excoriation of upper 
lip from the "snuffles." The navel failed to heal and on several parts of the body 
the skin was exfoliating. Note also peculiar deformity of the feet. 



Syphilis Neonatorum 

As previously alluded to, the infant may at birth appear per- 
fectly healthy. He may continue to thrive, especially if fed on breast 
milk. Before long, however — usually after from about one week to 
three months — the clinical aspect changes materially. The baby begins 
to breathe noisily, especially when it nurses, "sniffles," becomes 
hoarse, or loses its voice entirely. The nurse or the weather is blamed 
for the baby's "cold in the head," until examination reveals that 
the syphilitic coryza is associated with swelling of the nasal mucous 
membrane and occlusion of the anterior nares by a seromucous or sero- 
sanguinolent discharge and incrustation. Inspection of the mouth 
and throat often discloses grayish- white patches (plaques muqueuses) 
upon the mucous membrane of the mouth and pharynx, more rarely 
papillomatous vegetations, and occasionally edema glottidis, which lat- 
ter may lead to fatal termination. Not rarely the inflammation of 



4S4 



DISEASES OF CHILDREN 



the nasal mucous membrane extends to the nasal periosteum and peri- 
chondrium, arresting the development of the nasal bones, and giving 
rise to the peculiar sinking of the bridge of the nose which is generally 
designated "saddle nose." This is rather a late manifestation. 

The syphilitic manifestations augment from day to day. The skin 
assumes a peculiar light- or dark-yellow (copper) color, is dry and 
hard to the touch, and soon becomes covered by an eruption which 
is typical for its multiplicity and variability. Almost every kind 
of skin disease is represented. Papules, vesicles, pustules, smooth 
and scaly patches, tubercles, wheals, macules, hemorrhagic spots, sim- 
ple redness, scabs, ulcers, etc., vie with one another in their supremacy, 
and rhagades surround the different external orifices of the bodv 




Fig. 132. — Syphilitic pemphigus, especially marked on the soles of the feet. Xote 
also condylomata at vagina and anus. 



(angles of the eyelids and lips at the alae nasi, anus, labia vaginae, 
etc.). The hairy portions of the body also participate in the syphi- 
litic process. The hair of the scalp, eyebrows and eyelashes rapidly 
fall out and are very slow in returning. The nails undergo certain 
alterations, such as thickening, claw-like deformities, suppurative in- 
flammation (onychitis) and exfoliation (paronychia), the process not 
rarely extending also to the phalanges (syphilitic phalangitis, q.v.). 
In the majority of cases we find a bullous eruption which is pathogno- 
monic of grave syphilitic infection, i. e., pemphigus syphiliticus. It usu- 
ally sets in within the first week after birth as flaccid, yellow or brown- 
ish vesicles, surrounded by an areola of dry epidermis or excoriation. 
The bulla? vary in size from a pinhead to a cherry, burst readily and 
discharge a seropurulent or serosanguinolent content. They are dis- 



SPECIFIC COMMUNICABLE DISEASES 



485 



tributed all over the body, but particularly over the palms of the hands 
and soles of the feet — herein differing from nonsyphilitic pemphigus 
which but rarely affects these parts. In consequence of the inflamma- 
tory state of the skin, the superficial lymphatic glands are more or less 
implicated, the swelling often persisting long after disappearance of the 
primary cause. Enlargement of the epitrochlear glands, just above the 
internal condyle of the humerus, is especially common and of diagnostic 
importance. Special mention deserve also the syphilitic condylomata, 
especially at the anus and female genitals. They usually begin as sim- 
ple papules and are gradually transformed into luxuriant growths. 

\Vith the aforementioned clinical findings in view, it requires no 
sage to solve the problem of diagnosis. Now, if the physician bases 
his judgment upon the symptoms presented, does not allow himself to 




Fig. 133. — Congenital syphilis in eight-week-old baby. Note multiform eruption, 

rliagad.es, and exfoliation. 



be led astray by spurious histories (omnis syphiliticus mendax!), 
but goes right ahead and employs suitable antisyphilitic measures 
(see p. 494), the chances of rapid improvement and ultimate recovery 
are very good indeed. Otherwise, the syphilitic process often violently 
runs its destructive course, attacks one structure after another, one 
organ after the other, crippling the hapless infant for life, if it un- 
fortunately survives. 

The osseous system hardly ever escapes involvement. As in fetal 
syphilis (q.v.), the syphilitic bone affection consists principally of 
an osteochondritis and sometimes caries and necrosis. There is an 
overgrowth of the cartilage between the epiphyses and diaphyses of 
the long bones, often giving rise to painful circular swelling in the 
epiphyseal region and separation of the affected limb (spontaneous 



486 



DISEASES OF CHILDREN 



fracture), with consecutive loss of power (Parrot's pseudoparalysis). 
This process is usually (but not invariably) unilateral, herein differing 
from rachitis in which the epiphysitis is almost always bilateral. 
The skull presents enlargements (Parrot's nodes) of the parietal 
eminences and a buffer-like bossing of the frontal bone which is gen- 
erally designated "hot-cross-bun" tumor. Occasionally the frontal 
bone appears either unduly convex and prominent (frons Olympian) 
or keel-shaped, (Fig. 137) with a central ridge and lateral flattening. 
These syphilitic manifestations are often associated with craniotabes, de- 
layed (or premature) closure of the fontanelles and great brittleness 
of the milk teeth. 

The liver is often the seat of cellular infiltration (interstitial hepa- 
titis) or variously sized gummata, rarely large enough to be visible 




Fig. 134. — Congenital syphilis in a six-week-old. baby. Note maculopapular eruption 
on baby and on mother's hand. 



to the naked eye. The liver is enlarged, hard and uneven to touch, 
but palpable through the abdominal wall only in advanced cases. 
Marked syphilitic changes in the liver frequently give rise to icterus, 
acholic stools, and bile-colored urine. On the other hand, mild forms 
of the disease are usually entirely free from symptoms. 

Next to the liver, the spleen is most prone to suffer in syphilis. 
It is enlarged and readily palpable through the abdominal wall. 
Splenomegaly being of so common occurrence in early childhood, 
it is difficult to determine how much of this phenomenon is due to 
the syphilitic process and how much to other causes, especially rachi- 
tis. The younger the infant (under six months), the greater the 
probability of the perisplenitis being syphilitic in nature, especially 



SPECIFIC COMMUNICABLE DISEASES 



487 



if the splenomegaly is associated with other syphilitic symptoms, such 
as ''Parrot's nodes," condylomata, and ozena. 

Syphilis of the pancreas is not demonstrable during life, but it has 




Fig. 135. — Syphilitic dactylitis of right index finger in a child two rears old. 
(Xote normal left hand.) 

repeatedly been proved — by postmortem examinations — that the pan- 
creas is affected in a way very similar to that of the spleen. 

The intestines also are not rarely affected. Intestinal syphilis is 



488 DISEASES OF CHILDREN 

manifested chiefly by ring-shaped indurations of the muscles and 
mucous membrane, leading- to gradual constriction of the intestinal 
lumen. The pathologic process resembles that of "Peyer's patches." 
Clinically, intestinal syphilis gives rise to protracted diarrhea, often 
with fatal termination. 

Syphilitic changes (perivascular cellular infiltration; gummatous 
deposit) are occasionally met also in the kidneys and suprarenals (pa- 
roxysmal hemoglobinuria; nephritis), in the heart (symptoms of myo- 
carditis) ; in the lungs (pneumonia with slow course; spirochetes in 
the sputum), in the thyroid gland (struma); in the thymus (cyst or 
abscess); in the testicles (often greatly enlarged; hydrocele; arrested 
development), and in the ovaries (demonstrable postmortem; some- 
times by rectal, bimanual examination during life). 




Fig. 136. — Periosteal syphilis of left ulna in a child ten years old. 

Arteritis and periarteritis, gummatous deposits and sclerosis occa- 
sionally occur in the brain and spinal cord* as in the other organs of 
the body, and the concomitant symptoms vary with the seat of the le- 
sions. Chronic meningitis and lrydrocephalus with spina bifida are 
not rarely of syphilitic origin, and epilepsy, idiocy, local paralysis of 
the extremities and of the eye muscles, blindness, disseminated sclero- 
sis and tabes dorsalis have been occasionally traced to congenital 
syphilis. Also cases of syphilitic encephalitis are on record. The re- 
semblance between syphilis of the nerve system and tuberculosis should 
not be lost sight of. 

As already suggested the diagnosis of syphilis is very easy when 
the aforementioned symptom complex is in full bloom. Cases, how- 
ever, are not rarely encountered which are apt to test the skill of 



*P. C. Jeans (Jour. Am. Aled. Assn., Jan. 15, 1921) found involvement of the central nerve 
system in one-third of the cases examined, 



SPECIFIC COMMUNICABLE DISEASES 



489 



even the best diagnostician. I am referring especially to those which 
either run a very latent course from the beginning, or do so after a 
few weeks' antisyphilitic treatment. Every bit of information as to 
the past, personal ("snuffles," eruption, etc.) and family history (mis- 
carriages; persistent sore throat in the mother or father!) should be 
utilized to arrive at a correct conclusion. Old cracks and scars at 
the anus, mouth, nares, etc.; dark, mottled skin; old marks of healed 
ulcers in the mouth and throat; persistent ozena; intractible inter- 
trigo, etc. ; excessive brittleness of the milk teeth should all be care- 
fully looked into, and where doubt still exists the patient be given the 
benefit of the doubt and actively treated for syphilis — the rapidity of 




Fig. 137. — Syphilitic baby eleven months old. Xote keel-shaped deformity and boss- 
ing of greatly distended head. Baby is also mentally deficient. 

response to treatment at the same time serving as a differential point 
of diagnosis (therapeutic test). 

Wherever possible laboratory tests should supplement ordinary 
clinical examination. Of these, "Wassernrann's serum diagnosis of 
syphilis and Noguchi's luetin intradermic test are deserving of spe- 
cial consideration. In cases of doubt, the parents should be tested 
as well. 

AVith establishment of the diagnosis of syphilis, the remedies to 
be employed to eradicate the disease fortunately leave no room for 
speculation. The treatment, which will be fully outlined in the sub- 
sequent pages (see page 494), should be carried out energetically 
and systematically and continued until apparently every vestige 
of the disease has been completely removed. 



490 DISEASES OF CHILDREN 

Inadequate treatment not only greatly mars the prognosis of syph- 
ilis as to life and recurrences, but only too often is responsible for 
the development of the symptom complex which is generally described 
as "parasyphilis." This group of syphilitic manifestations (syphilitic 
cachexia) consists of extreme debility, marasmus (especially in the 
artificially fed) ; profound anemia (pseudoleukemia), obstinate gas- 
trointestinal and bronchial catarrh, otitis (deafness), disposition to 
rachitis, cretinism and idiocy, and lowered power of resistance to 
divers acute infectious diseases. "While the mortality of the carefully 
treated syphilitics is comparatively small, those who are carelessly 
managed often succumb to intercurrent diseases, even of the most 
trifling character, not rarely die suddenly without apparent cause, 
and if they survive, remain decrepit for life, and a source of horrible 
misery to future generations. 

Syphilis Hereditaria Tarda s. Lata 

Late hereditary syphilis attacks the offspring of syphilitic parents at 
any period between early childhood and adolescence. The children 
thus affected may or may not have shown manifestations of congeni- 
tal syphilis during intrauterine life or soon after birth. The symptoms, 
however, are more pronounced in those who had been treated inade- 
quately or not at all. Late hereditary syphilis essentially corresponds 
to the tertiary stage of acquired syphilis. Like the latter itjshows 
a predilection for the eyes and osseous system; but no structure or 
organ of the body is free from its destructive effects. 

As will be presently demonstrated, the lesions of late hereditary 
syphilis may be numerous and grai T e, but not always strictly pathog- 
nomonic of this disease. There is, however, one group of syphilitic 
manifestations, which, if present, invariably betrays the existence of 
a syphilitic taint. 

This symptom complex is generally described as the "triad of syph- 
ilis" and consists of the following manifestations: 

1. The So-called Hutchinson Teeth. — The characteristic teeth of 
syphilis are the two upper central incisors of the permanent set. The 
teeth are chalky, ill-developed, small, and irregularly placed. They 
taper from the free border to the base, hence the term "screw-driver 
teeth," and present a broad, semilunar notch in the center to the 
edge. They should not be confounded with the brittle and decayed 
milk teeth observed in infantile syphilis or rickets, and the irregu- 
larly implanted teeth associated with deformed palate or dental arches. 



SPECIFIC COMMUNICABLE DISEASES 491 

2. Interstitial Keratitis. — This almost invariably symmetrical af- 
fection begins with corneal haziness which rapidly increases until the 
entire cornea is in a condition of partial opacity resembling "ground- 
glass." It is associated with congestion of the ciliary region and 
slight inflammation of the conjunctiva, and in severe forms of the 
disease, with iritis, retinitis and choroiditis. In addition to the cor- 
neal gray-colored patches, abruptly margined, crescentic patches of 
salmon tint are often present on the corneal surface, this sign of 
vascularity not rarely spreading over the whole cornea and giving 
rise to a deep plum tint of purple redness. Excessive lacrimation 
and photophobia prevail from the start, in marked cases reducing 
the patient to a state of practical blindness. The disease runs a very 
slow course, from about three months to a year or longer, and, when 
it subsides, leaves behind more or less marked corneal opacity and 
visual impairment. 

3. Deafness. — This condition is not accompanied by any inflamma- 
tory symptoms. It is caused by syphilitic involvement of the laby- 







. *>-"• ;-± 


'?' \ 


« pmui " 


^KP 



Fig. 138. — Syphilitic ' ' Hutchinson teeth." Note semilunar notches in central in- 



cisor: 



rinth (often deafness of both ears). The deafness very rarely clears 
up spontaneously and entirely. On the contrary, even under active 
treatment defective hearing is the rule. This peculiar form of deafness 
often precedes or follows the attack of keratitis and is gradual in 
development. 

The bone lesions of late syphilis consist of an osteoperiostitis, or soft 
gummatous periostitis, especially of the tubular and cranial bones. 
The most frequent seat of the disease is the tibia, then follow the 
ulna and radius, the humerus, femur, clavicle, the bones of the skull, 
the phalanges and sternum. Syphilis of the shaft of the tibia usually 
gives rise to a characteristic "saber-shaped" deformity of the tibia, 
the so-called "tibia en lame de sabre." It differs from the rachitic 
deformity of the tibia by its crest being rounded (in rickets it is 
sharpened) and its internal and external surfaces convex (in rickets 
they are flat or concave). 

The cranial bones are affected in a manner similar to that of syph- 



492 



DISEASES OF CHILDREN 



ilis neonatorum. (See page 483.) Ulceration' of the soft palate and 
throat, and perforation of the hard palate and nasal bones with sec- 
ondary "saddle-shaped" deformity of the nose are of common oc- 
currence. 

Syphilis of the phalanges (syphilitic dactylitis) is characterized by 
a puffy, fusiform, or spindle-shaped swelling. It affects the fingers 
more often than the toes. The inflammation may begin either in the 
connective tissue and ligaments or in the periosteum and bone. If 
let alone the disease progresses rapidly and leads to protracted 
osteomyelitis with ankylosis, shortening and permanent deformity of 
the affected parts. Syphilitic dactylitis differs from the tuberculous 




Tig. 139. — Gumma of the right parietal bone in an eight-year-old boy suffering from 

syphilis hereditaria tarda. 

variety, which it greatly resembles, by its being less common, often 
symmetrical and accompanied by other syphilitic lesions. The tuber- 
culin and Wassermann reactions are decisive in the diagnosis. 

Occasionally the joints participate in the syphilitic process, but 
the affection is rarely of serious nature. It essentially consists of 
a recurrent synovitis with thickening and ankylosis, and may. readily 
be mistaken for articular rheumatism. The absence of fever and 
redness and the history of syphilis usually clear up the diagnosis. 

The skin sometimes presents subcutaneous gummata which, when 
neglected have a great tendency to break down and to form large 
phagedenic ulcers. They are most frequently met with on the face 
and upper part of the thighs or legs. They promptly yield to ener- 



SPECIFIC COMMUNICABLE DISEASES 493 

getic antisyphilitic treatment — a feature to be borne in mind in the 
differential diagnosis between syphilitic and tuberculous ulcers. 

The lymphatic system and the viscera, especially the liver and 
spleen rarely fail to show late syphilitic manifestations. The latter 
are essentially identical with those described in connection with con- 
genital syphilis neonatorum. (See p. 476.) 

Finally, mention may be made of the tendency of late syphilis 




Fig. 140. — Syphilitic osteoperiostitis of the tibia, — ' ' Saber-shape-def ormity, ' ' — and 
of the nasal bones, with high degree of rachitis. 

to arrest the development of the child's body and mind. Dwarfism 
and infantilism are not rarely traceable to this baleful cause. Indeed, 
appreciating the gravity, multiplicity and complications of the syph- 
ilitic lesions it is rather surprising that the aforementioned bodily 
and mental deteriorations are not more rampant. 

Notwithstanding the apparent explicitness of the symptomatology, 
the diagnosis of late hereditary syphilis is by no means a simple 



494 DISEASES OP CHILDREN 

proposition. It is especially difficult in cases complicated by inter- 
current diseases, e. g., tuberculosis or rickets. 

The specific history; the simultaneous occurrence of lesions in va- 
rious parts of the body; the tendency of the bone lesions to be sym- 
metrical; the appearance of the manifestations very frequently in the 
midst of apparently perfect health; and, finally, the quick response 
to antisyphilitic treatment are more or less decisive in the diagnosis. 
Of course, all doubt is removed by positive microscopic or bacteriologic 
findings, especially serum diagnosis. 

Acquired Syphilis 

The newborn may acquire syphilis either intrapartum, by coming 
into contact with a chancre in the parturient canal, or while nursing 
at the breast of a woman (mother or wet-nurse) in the contagious 
state of syphilis. The disease may further be acquired by infants and 
older children practically in the same manner as by adults. It is well 
to remember that the newborn with secondary symptoms of syphilis 
may transmit the disease to healthy people through fondling, the. use 
of articles coming in contact with syphilitic lesions, etc. I have in 
mind two older, previously healthy brothers, who have in this manner 
acquired syphilis from a syphilitic newborn. 

The course of acquired syphilis in children is identical with that 
observed in adults, except that it is prone to be more rapid and 
violent. 

The primary lesion (chancre) is usually found in the child's mouth 
(from kissing or sucking of infected nipples), or on the perineum (from 
washing of baby's buttocks with infected hands). Occasionally the 
primary sore is on the penis, as a result of infection during ritual 
circumcision. 

Treatment. — The treatment of syphilis is alike in both forms of 
the disease — inherited (early and late) and acquired. It should be 
begun as soon as the diagnosis has been established. Temporizing 
is often fatal. Mercury in some form is the only remedy that is 
certain in its results, and should be administered continuously until 
every vestige of the disease has apparently disappeared, and then given 
at intervals of from two to six weeks for a total period of from two 
to three years. Calomel is the preparation par excellence. One-tenth 
to Y+ grain twice (to an infant) or thrice daily (to an older child) 
will usually suffice. Now and then we may also employ sodium iodide 
(!/2 grain for every year of the child's age) three times a day, or syrup 
of iodide of iron (5 drops for an infant under one year, 10 drops for 
two years, and 15 drops for over five). To hasten saturation of the 



SPECIFIC COMMUNICABLE DISEASES 495 

system with the mercury, we may, in addition, resort to mercury in- 
unctions. From 10 to 30 grains of mercurial ointment may be rubbed 
in once a day alternately into the axilla, groin, abdominal wall, calf 
muscles, and loins. To prevent excessive salivation the oral cavity 
should be washed twice daily with a 2 to 5 per cent solution of chlorate 
of potash or tincture of myrrh. Syphilitic ulcers should be cauterized 
with nitrate of silver solution (3 per cent to 10 per cent). Keratitis 
calls for local use of atropine sufficient to keep the pupils widely 
dilated, hot poultices (by means of moist hot cloths), occasional dust- 
ing of calomel over the corneal ulcers, protection from bright light 
(dark room or smoked glasses), and, of course, internal administration 
of mercury and the iodides. The great majority of cases of osteitis 
yield promptly to constitutional treatment, but where the necrosis 
is pronounced the management must follow ordinary surgical lines. 
Persistent condylomata will rapidly disappear after a few applications 
of a 5 per cent salicylic-resorcin-collodion solution, or occasional 
painting with caustics. Onychia and paronychia should be treated by 
local bichloride baths (1:2000), once or twice daily, and dusting with 
calomel 1 part, gum arabic 1 part, and stearate of zinc 10 parts. In- 
durated lymph glands usually yield to potassium iodide ointment, 
while suppurating glands require surgical interference. 

The general health of the patient should not be lost sight of. Other 
conditions being favorable, a syphilitic mother should nurse her 
syphilitic child. This being impossible, the infant should be put on 
properly modified cow's milk, or on the breast of a wet-nurse, who 
has emerged from an attack of syphilis without serious consequences. 
In older children also particular attention should be paid to good nu- 
trition. The tendency of rickets complicating syphilis should be 
borne in mind. Hydrotherapy, plenty of fresh, pure air, and general 
tonics are essential to success. 

Pediatrists are not particularly in favor of salvarsan in children, be- 
cause it is difficult to administer it in young babies,* and is not at 



*The Lowy Laboratory gives the following directions for the administration of neoarsphen- 
amine in infants and older children: 

Wrap the child in a blanket (as for intubation), lay it on the table on its side and place a 
very low pillow under its head so as to have the head level with the line of the spine; then 
sterilize the side of the neck. The external jugular vein will be found by drawing a straight 
line from the outer portion of the lobe of the ear directly to middle of the clavicle. By placing 
the little finger or a pencil a little above the clavicle directly in line with the clavicle, and exert- 
ing gentle pressure, the jugular will become distended so as to become visible. Having properly 
distended the vein, take a 20 gauge needle, insert it at the lower portion of the jugular vein 
about one-half inch above the place where pressure is being exerted. With a firm push insert 
the needle into the vein, care being taken, however, that the point of the needle is towards the 
heart. When the blood begins to flow, without attempting to remove the needle, apply the 
adapter supplied with Solution Arsphenamine-Lowy, and permit solution to flow in very slowly, 
the dose being 20 c.c. per thirty pound body weight. It is sometimes advisable to measure out 
the quantity desired into the barrel of the syringe and use the barrel of the syringe similar to 
a gravity container, as in that fashion the amount used can be accurately gauged,. Five to six 
injections should be given at one week intervals. It may be necessary to give a series of these 
injections. 



496 DISEASES OP CHILDREN 

all free from serious consequences, and, furthermore, because it shows 
no superiority over the mercury and iodide treatment. The dosage 
of salvarsan or neosalvarsan is 0.005 to 0.01 gram per kilo of body 
weight. It should be administered once or twice a week until the Wasser- 
mann reaction proves negative on several examinations. Syphilitic 
children should be kept under observation for several years after ap- 
parent recovery from the disease. 

J. A. Fordyce* and I. Rosen combine mercury with neoarsphenamine 
treatment. The latter is administered intramuscularly, half of the solu- 
tion into each buttock, in the following doses at weekly intervals : 0.075 
gm. for infants from 3 to 8 weeks ; 0.1 gm. from 2 to 6 months ; 0.15 gm. 
from 6 to 12 months ; 0.15 to 0.2 gm. from 1 to 2 years. These doses are 
employed in courses of from 6 to 8, followed by rest periods of from 4 to 
6 weeks. 

Frambesia 

(Yaws) 

Frambesia is caused by the Treponema pertenue, a slender spirillum 
resembling the spirocheta of syphilis. The mode of conveyance of the 
disease is still obscure, but probably occurs by direct contact. In 
endemic countries (Philippine Islands, Ceylon, Tropical Africa, Fiji, 
and Samoa) this affection is quite prevalent among young children. 
One attack seems to confer permanent immunity. 

The incubation period lasts from two to five weeks, in the last few 
days manifesting itself by irregular temperature, muscular and articu- 
lar pain, anorexia and lassitude. About a week later a papule makes 
its appearance which soon turns into a pustule, often perforated by a 
hair. On further growth this primary lesion assumes a raspberry-like 
appearance. The secondary eruption develops within from one to 
three months after the primary lesion, like the latter is preceded by 
general febrile symptoms, and like it also consists of cauliflower-like 
excrescences which may be distributed throughout various parts of the 
body but more especially over the face and neck and anal and genital 
regions. The lesions may recur at short or long intervals for years, 
especially if left untreated. Bone changes, especially in the feet and 
hands (dactylitis) are quite common; and as a result of extensive 
ulcers w T e occasionally meet with serious deformities of the hands and 
feet. Ulceration and necrosis of the frontal bone also is not infrequent. 
Cases presenting these symptoms may readily be mistaken for syphilis. 
Indeed, before the discovery of the Wassermann reaction some authors 
were inclined to look upon yaws as a type of syphilis. This view has 
proved erroneous, for it has frequently been shown that a patient with 



*Jour. Am. Med. Assn., Nov. 20, 1920. 



SPECIFIC COMMUNICABLE DISEASES 497 

yaws may contract syphilis and vice versa. However, while frambesia 
is a disease sui generis, it has been found like syphilis to respond to 
intravenous injection of neosalvarsan. In the way of prophylaxis, it is 
important to avoid solution of continuity of the skin when handling 
patients suffering from the yaws, and to protect all abrasions by means 
of collodion, adhesive plasters and antiseptics. 

Leprosy 

Leprosy is an infectious disease pursuing a chronic course due to 
an acid-fast bacillus, the Bacillus leprce (discovered by Hansen of 
Bergen in 1871) which resembles the tubercle bacillus. It is an un- 
common disease, especially in sanitary countries. In the following 
table Dr. Heiser gives an approximate estimate of the proportion of 
lepers to the population of different countries. 

Japan 1 in 1000. 

Philippine Islands 1 in 1400. 

India 1 in 2000. 

United States 1 in 100000. 

Xew Zealand 1 in 200000. 

Australia 1 in 200000. 
The exact mode of transmission of the disease is still unknown. It 
is not congenital in character. Fifty children born of leprous parents 
at the Culion Leper Colony showed no traces of leprosy at birth. Some 
of them, however, contracted the disease later, by remaining in close 
contact with their mothers. Kitasato maintains that over 7 per cent of 
the children of lepers sooner or later acquire the disease. The incuba- 
tion period is of variable duration, in some instances several years. 
Once the disease is established it is found that the bacilli entering the 
human body have multiplied enormously and become enclosed in 
plasma cells (lepra cells). 

We generally distinguish three varieties of the disease, as follows: 
1. Anesthetic Leprosy. — In this form the anatomic changes (infiltra- 
tion) occur principally in the nerve system. It ordinarily begins with 
shooting pain, particularly in the ulnar and peroneal nerves, flushing, 
erythema, of the face, glossy skin and muscular twitching. It is soon 
followed by anesthesia of large surfaces of the body. With further 
progress of the disease and consecutive destruction of the nerves, trophic 
changes, especially of the extremities scon supervene, accompanied by 
ulceration of the affected structures which fail to heal and gradually 
undergo total destruction (amputation of terminal extremities). This 
process is often associatetd with marked contractures, e. g., of the thumb 
and fingers (main en griff). 



498 



DISEASES OF CHILDREN 



2. Tubercular, Nodular or Hypertrophic Leprosy.— This variety is 
usually ushered in by a macular eruption and febrile disturbance. At 
first the ears, nose and face are infiltrated. Gradually the eruption as- 
sumes a nodular, tubercular consistency, resembling a crop of red po- 
tatoes, and spreads all over the body. In late stages the contour of the 




Fig. 141. — Case of leprosy in a child shoAving infiltration especially in ears, lips 
and hands. Leprous nodules in the left arm. Example of tubercular, nodular, hyper- 
trophic leprosv. (After J. C. DaCosta, Jr., Handbook Medical Treatment, F. A. 
Davis Co.) 



face resembles that of a lion. Infiltrations occur also in the larynx, 
lungs and eyes, but perforating ulcers are not as common as in the anes- 
thetic variety. 



SPECIFIC COMMUNICABLE DISEASES 499 

3. Mixed Leprosy, is characterized by the intermingling of the princi- 
pal symptoms of the two other varieties of the disease, and is the most 
common type met with in leper asyhims. 

The diagnosis presents no difficulties in advanced cases, but in the 
early stages leprosy may be mistaken for lupus or syphilis, and in 
doubtful cases it may become necessary to search for the acid-fast lepra 
bacilli in the scrapings of the affected tissues, in order to arrive at a 
prompt decision. 

Treatment. — Isolation and segregation of the patient in a leper hospi- 
tal until at least two years after total disappearance of the clinical mani- 
festations as well as the microscopic findings. Even then lepers should 
be kept under surveillance. Persons with open wounds should not come 
in close contact with lepers. The active treatment consists of hypo- 
dermic injections of the following preparation (Unna's modification) : 

IJ Cnaulmoogra oil (obtained from the seeds of gynocardia odorata)* 

Camphorated oil aa 30-0 

Eesorcin 2.0 

Mix and dissolve with aid of heat and filter. 
Sig. — Five to fifteen drops hypo dermic ally once a week. Quicker results 

are obtained when the injections are made in the infiltrated areas. 

In cases where severe reactions follow {e.g., fever, cardiac distress), 
the dose may be reduced in quantity but given more frequently. Pro- 
longed hot bicarbonate of soda baths act beneficially. Ulcerations and 
other symptoms are treated according to indications. 

Pestis Bubonica 

(Buboxic Plague, Black Death) 

The history of this dreadful scourge is traceable to the old Bible. 
In recent years it raged in China and India and sporadic cases were 
observed in port cities of Italy, Scotland and England as well as those 
of South America and the United States (Xew Orleans, Pensacola, 
Galveston, Seattle and San Francisco). Most recently several cases of 
the plague have been reported from Mexico and Texas. f The disease is 
spread mainly through infected rats, by bites of rat-fleas. It is caused 
by the Bacillus Pestis, which was discovered by Yersin and Kitasato in 
1894 and is regularly found in the circulating blood of plague patients as 
well as fn the sputum (pneumonic plague), enlarged glands, spleen and 
other organs of the body. 



*Walker and Sweeney (Jour. Infect. Dis., 26, 1920) have recently demonstrated that this oil 
contains bactericidal substances that are about one hundred times more potent than phenol, and 
that its action is specific for the acid-fast group of bacteria. 

fAnalysis of 26 cases of Beaumont and Galveston, bv M. D. Levy (Texas State Journal, 
October, 1920). 



500 DISEASES OF CHILDREN 

The incubation period ordinarily lasts two or three days, but oc- 
casionally may be of much longer duration. The attack is ushered in 
with chills, high temperature, mental depression, delirium and often 
convulsions. These symptoms are soon augmented by the appearance 
of painful swelling of the inguinal (bubo) and axillary glands, pe- 
techia* (hence the name of "black death") and occasionally internal 
hemorrhages, and in fatal cases muttering delirium and coma. Septi- 
cemic plague with early prostration, vomiting and dysentery and low 
temperature, ends fatally even before the appearance of the bubo, while 
mild cases, pestis minor, may not be ill enough to go to bed and can only 
be diagnosed by the finding of the bacilli in the glands or blood. In 
about ten per cent of cases the plague appears in the form of pneumonia 
(pneumonic plague). The symptomatology of this type of the disease 
greatly resembles the so-called epidemic influenza pneumonia, character- 
ized by extreme dyspnea, profuse bloody expectoration, cyanosis and 
heart failure, and is almost invariably fatal. It has often been observed 
that patients surviving six days show a tendency to recover, although 
convalescence is slow and not rarely marred by complications. The 
glands usually suppurate and either break spontaneously or have to be 
incised. The mortality as a whole ranges between 60 and 90 per cent. 
Postmortem examination usually reveals involvement of the spleen, 
lungs, liver, heart and kidneys, all more or less studded with small, con- 
fluent hemorrhages. 

Treatment. — Prophylaxis is most essential. Eats and their breeding 
places should be promptly destroyed. All patients should be strictly 
isolated, and persons, as well as animals, coming in contact with them 
quarantined. Ships carrying suspicious cases should be detained. In- 
fected buildings should be fumigated and if possible destroyed. 

Prophylactic vaccines of Haffkine and others administered hypo- 
dermically in the arm twice at an interval of ten days affords sure im- 
munity against the plague for about three months. It has recently been 
shown also that Haffkine 's vaccine in combination with Tersin's serum 
(live bacilli injected into a horse) is potent to reduce the mortality to 
less than 20 per cent. Similar results are claimed for Lustig's serum 
with antitoxic properties (obtained by immunizing horses to the endo- 
toxin of the bacillis pestis). The serums are given intravenously as well 
as in the affected glands. 

Aside from the specific treatment special attention is devoted to the 
heart, nutrition and general comfort of the patient. 

Physicians and attendants of plague patients, especially of the pul- 
monary type, should wear face masks of canton flannel with eyes of cel- 
luloid. 



CHAPTER VIII 

DISTURBANCES OF METABOLISM 

Marasmus, Athrepsia, Infantile Atrophy 

(Pedatrophy) 

The nature of this appalling infantile wasting is still shrouded in 
mystery. It is apparently only a functional disorder, a form of in- 
testinal autointoxication, arising from nonassimilation of the food 
consumed, since the organic lesions (atrophic patches in some portions 
of the intestinal tract and indefinite degenerative changes in the 
lungs, liver and kidneys found postmortem) are not uniform, and 
rapidly disappear when the atrophic infant is put on a suitable diet, 
which may vary from an ideal breast milk to some proprietary arti- 
ficial food (!). In this group, of course, are not included cases of 
marasmus accompanying tuberculosis, syphilis and the like. 

Whatever the pathology and cause, the symptomatology is very 
pathognomonic. The apparently normally born infant, after thriving 
fairly well on the milk mixture it has been receiving, begins to show 
signs of ill health and arrest in weight. The food disagrees, it is 
occasionally vomited or regurgitated. The stools are either consti- 
pated, dry and soapy, or green and frequent, scanty in quantity, and 
contain undigested particles of food. The child suffers from colic, 
especially soon after feeding, is very restless, cries and whines piti- 
fully, sleeps poorly, and do what you will, emaciation sets in and 
continues at a rapid pace. Before long the fontanelles, the eyes 
and cheeks are sunken (except for the small cushions of fat, "sucking 
pads," over the buccinator muscles) ; the nose and chin pointed; the 
abdomen is at first prominent but later retracted, the skin wrinkled, 
often hanging in folds, and, adding to this, the earthy pallor and 
senile expression of the face, the poor creature is a sight dreadful to 
behold. Though dried up to mere skin and bone, with respiration shal- 
low and pulse bad, the infant keeps on fighting for life for weeks and 
months, not rarely successfully. On the other hand, sudden death may 
occur when least expected. 

Unless wrecked by intercurrent diseases, those showing tenacity 
to life, and coming under observation not entirely in a hopeless state, 
stand some chance to regain their vitality and to recover com- 

501 



502 



DISEASES OF CHILDREN 



pletely. The prognosis depends also upon the duration of the maras- 
mus, the age of the patient — it is more favorable in infants over four 
or five months than in younger ones — and the care he can receive from 
those in attendance. The concurrence of complications or sequelae, 
such as atelectasis, edema, pneumonia, colicystitis, pyelonephritis, os- 
teitis, general furunculosis and the like, greatly mar the chances of 
recovery. 

Treatment. — As athrepsia almost invariably occurs in artificially 
fed infants, the line of treatment which at once suggests itself is to 
supplant the artificial food by human milk. Indeed, through such 
a change miraculous improvement in the infant's condition may often 




Fig. 142. — Marasmus in a child ten months old. Note "senile face. 



be observed within a very few days, requiring no further treatment 
to complete prompt and uneventful recovery. Wet nursing, therefore, 
should be the treatment of choice, even if it be only for a month or 
two, after which period cow's milk feeding may frequently be resumed 
with success. Athrepsia in breast-fed babies is usually due to an ex- 
cess of fat or some other constituent in the milk. In such cases 
the difficulty may often be surmounted by allowing the baby to nurse 
only from five to ten minutes at a time, and giving it 1 or 2 ounces of 
plain or cereal water, or diluted lime water, before and after each 
feeding, or a light skimmed milk mixture after nursing. On the other 



DISTURBANCES OF METABOLISM 503 

hand in some cases there is a deficiency in the food elements and the 
persistent inanition is responsible for the athrepsia. When the serv- 
ices of a wet-nurse are not obtainable (for financial or other reasons), 
an attempt should be made to feed the baby on condensed or dry milk 
in low dilution with plain or barley water. In a number of cases fat- 
free milk (1:1 or 2:1), in small quantities to begin with, proves useful, 
and to bridge over the critical period protein milk (1:1) may be tried, 
occasionally with splendid results. Finally, malt soup for reasons 
rather difficult to explain (unless it be assumed that the marasmus is 
the result of acid intoxication which is arrested by the carbonate of 
potash of the malt soup) will often, within a short time, convert a 
baby reduced to skin and bone into one of perfect beauty. 

Lavage and colon irrigation are useful in all cases. The latter should 
be employed daily; the former every alternate day. or more often, 
if the return water contains large quantities of mucus, and the vomit- 
ing persists. In the latter event it is often of advantage to add a 
little boric acid or bicarbonate of soda to the sterile water used for 
stomach washing. Of medicinal agents, in addition to an occasional 
dose of calomel, pancreatin is the only remedy to place some reliance 
upon. One or two grains each of pancreatin and bicarbonate of soda 
may be administered after feeding. 

The mouth of the infant should be kept scrupulously clean, and 
the buttocks dry and clean, to prevent stomatitis and intertrigo, both 
of which form frequent complications. The child should not be left 
too long in a recumbent posture, lest decubitus or passive pulmonary 
congestion supervene. For details of treatment of atelectasis, edema, 
and other complications the reader is referred to the respective chap- 
ters on the subjects. 

Outdoor life and plenty of fresh air while the patient is indoors 
are essential to successful management of the cases in question. When- 
ever possible the child should summer in the country. Above all, 
however, breast milk is the specific for marasmus, in the way of pro- 
phylaxis as well as cure. (See "Tuberculosis" and "Syphilis".) 

Rachitis 

(Rickets, The English Disease) 

Rickets is one of the most common affections of early childhood. 
It prevails to a greater or less extent in almost all parts of the world, 
but shows a predilection for poorly born, poorly nourished (also 
among the well to do) and poorly housed children of temperate zones. 
The immediate cause of rickets is the absence or deficiencv of im- 



504 



DISEASES OF CHILDREN 



portant elements* in the food or failure of the organism to assimilate 
the same in sufficient quantity. J. A. Schabad who has made a very 
exhaustive study of the subject (Arch. f. Kinderheilk., Vol. 54, Nos. 
1 to 3), is of the opinion that the pivotal point in the morbid mechanism 
of this disease is the metabolism of phosphorus and not of calcium. In 
the evolution of rachitis there is an increased elimination of both of 
these substances. The increased excretion of phosphorus is greater than 
can be accounted for by the amount of this substance and the equivalent 
amount of calcium contained in the bones, so that it is probable that the 




Fig. 143. — Kachitic "frons quadrata" in an infant thirteen months old. 

nervous tissues share in the pathologic process. The increased phos- 
phorus elimination is in the feces, while that in the urine is really less 
than the normal (hypophosphaturia) . The ratio between the phosphorus 
content of the urine and that of the feces is changed. The normal ratio 
in nursing infants, 80:20, becomes in rickets 65:35, while in artificially 
fed infants and in older children the normal ratio of 60 :40 is practically 
reversed to 40:60. In the convalescent period this disturbed ratio of 
phosphorus elimination is gradually restored to normal, while the 
total excretion of phosphorus reaches the subnormal. At the same 
time there is a relatively great increase in the urinary phosphorus, the 

*Vitamines. (See p. 114.) 



DISTURBANCES OF METABOLISM 



505 



ratio becoming 75:25. There is a close relationship between the cal- 
cium and phosphorus content of the feces; increase in the intestinal 
elimination of calcium goes hand in hand with a phosphorus reten- 
tion and vice versa. As its direct and most conspicuous result, Ave 
have a great diminution of the inorganic elements of the bones (barely 
35 per cent, whereas in normal bone they amount to 65 per cent), exag- 
gerated production of epiphyseal cartilage, excessive cell proliferation 
beneath the periosteum, and incomplete ossification of the new osseous 




Fig. 144. — Bachitic beading of the ribs, 



and bow-legs. 



tissue. The same process takes place in the centers of ossification of the 
flat bones. This is especially true of the cranial bones, giving rise to 
areas of thickening (bosses) and relative thinning (craniotabes). As 
the disease advances, chronic inflammatory changes occur also in the 
different soft structures (muscles, arteries, etc.) and organs (spleen, 
liver, nervous system, etc.) of the body, leading to a complex pathologic 
entity sui generis — entirely distinct from any other diseased process. 
This pathogenic process is very insidious in its onset and its course ; 
hence in the beginning rickets is very apt to be overlooked, especially 
if following upon some other illness. 



506 



DISEASES OF CHILDREN 



As a rule, the initial symptoms are very vague, and consist of re- 
current indigestion, restlessness and debility : a nonpathognomonic 
group of symptoms, rarely arousing the anxiety of those in charge 
of the patient so as to seek medical advice. When seen by the physi- 
cian, therefore, the disease is usually in full bloom. 

The skull is relatively large, the forehead broad and prominent 
in profile (frons quadrata). The parietal eminences project strongly, 
and the fontanelles, especially the anterior one, and the sutures fail 
to close in due time. The occiput is thinly covered with hair or 




Fig. 145. — High degree of rachitic spinal curvature. 



entirely bald, and here and there yields to pressure with the finger 
(craniotabes). These soft spots are usually quite pronounced when 
the rachitis sets in during very early infancy. 

The local baldness is the result of undue pressure and friction of 
the occiput against the pillow, and the effect of profuse perspiration 
which is most marked at the posterior portion of the head. The sweat- 
ing and rubbing of the head, both very early symptoms of rickets, in a 
way are correlated, and probably due to cranial hyperemia. The 
rachitic process is also accompanied by more or less severe local 
pain in the bones, and the little patients will often cry when lifted 



DISTURBANCES OF METABOLISM 



507 



and are even annoyed by the pressure of ordinary bed covering (hence 
kicking off of the blankets). 

The lower jaw, instead of being rounded, becomes flattened, and 
its alveolar edge is turned inward. The upper jaw is also more or 
less deformed, and the teeth, which are late and irregular in coming, 
are asymmetrically set, conforming with the altered shape of the jaws. 
Owing to the deficiency in enamel the teeth soon turn yellow, brown- 
ish or black, are streaked and brittle and subject to rapid decay. 

The rachitic thorax is very typical in appearance. The clavicles are 
more sharply curved than in the normal, and occasionally infracted; 
the costochondral junctions are thickened, bead-like in shape (most 
marked from the fourth to the eighth rib), assuming in their sloping 
course from above downward a rosary-like appearance (rachitic ros- 
ary) ; the sides of the thorax are flattened and the sternum projects, 




Fig. 146. — Rachitic bow-legs, * ' jug "-shaped abdomen, and separation of epiphyses 

— ' ' double- jointed. ' ' 



as in birds, hence the so-called "pigeon" or "chicken" breast (pec- 
tus carina turn), and, finally, the lower lateral diameter is widened. 

The vertebral column, although rarely affected in mild forms of 
rachitis, invariably suffers in severe and protracted cases. The de- 
formities most frequently met with are kyphosis and scoliosis. The 
kyphosis or backward curvature usually extends from the middorsal 
to the sacral region. It differs from tuberculous kyphosis by being 
rounded, and in the early stages reducible when the child is placed 
upon the abdomen and the thighs are overextended. (See "Spondy- 



508 DISEASES OF CHILDREN 

litis," p. 462.) Rachitic lateral curvature or scoliosis is produced by 
the relatively heavy weight of the head upon the yielding (muscular 
and ligamentous insufficiency) vertebral column. The condition is 
further aggravated by allowing the patient to sit up or walk at too 
early an age and for too long periods, and by the habitual unequal 
distribution of the encumbrance. As regards the latter, it will be 
noted that right-handed persons usually carry their children on the 
left arm, so as to have the right hand free, and in consequence, the 
right pelvis of the child is lifted upward, the right shoulder tilted 
dowirward and the middle spine shoved laterally — lateral scoliosis with 
the spinal convexity to the left. While rachitic scoliosis is most fre- 
quently observed in early childhood, rickets undoubtedly forms also 
the principal cause of the so-called postural scoliosis of school chil- 
dren, the curvature being merely an exaggeration of the former con- 
dition. Rachitic scoliosis (Fig. 145) is to be differentiated from congeni- 
tal scoliosis (very rare ; as a rule associated with other congenital deform- 
ities) ; cicatricial scoliosis (following operation for purulent pleurisy) ; 
paralytic scoliosis, in association with poliomyelitis, etc. (Fig. 189) ; 
spondylitic scoliosis, usually kyphoscoliosis (see "Spondylitis," p. 
462) ; and static scoliosis (in congenital or acquired shortening of one 
lower extremity). Although, as previously alluded to, rachitic scoliosis 
is reducible in its early stage, if let alone for a long period, the deform- 
ity is apt to remain permanent, notwithstanding the disappearance 
of the other symptoms of rachitis. 

The extremities very rarely escape involvement. In the upper ex- 
tremities we usually find marked enlargement of the epiphyses at the 
wrists, and less frequently at the elbow. In creeping infants the 
radius and ulna are often curved and sometimes infracted, and in 
severe cases the hand is separated as it were by a furrow — "double 
jointed." Occasionally there is also an enlargement of the ends of the 
metacarpal bones or the phalanges. 

By far more marked are the deformities of the lower extremities. 
The soft tibia and fibula are ill prepared to balance the weight of the 
body. The flimsy fundament thus tumbles under its encumbrance. 
The hapless patient learns to walk late and with difficulty, or, as it 
were, "forgets" or unlearns how to walk, or refuses even to stand be- 
cause of pain in the legs. If he continues to walk, the tibige and fibulas 
bend either outward (bowlegs — genu varum ; O-shaped) inward (knock- 
knees — genu valgum; X-shaped) forward (saber-blade shaped) or, in 
severe cases, simultaneously in different directions. Similarly to what 
occurs in the upper extremities, there is also an enlargement of the 
epiphyseal ends of the bones, and occasionally infraction of the diaphy- 
ses. Children sitting crossed-legged may present also more or less pro- 



DISTURBANCES OF METABOLISM 



509 



nouncecl curvatures of the femur and pelvis. Rachitic flat-foot is rare. 

The course of these deformities varies. In the majority of mild and 
moderately severe cases spontaneous recovery occurs with improvement 
of the general condition. On the other hand, in extreme cases, where, as 
a rule, growth is greatly retarded, the curvatures persist and require 
forcible corrective measures, or surgical interference. 

The muscles generally participate in the rachitic process. They are 
thin and flabby and partly responsible for the difficulty in sitting and 
walking ("pseudoparalysis") ; abdominal distention ("potbelly") ; and 




Fig. 14:7. — Rachitic knock-knee in girl six years old. 



for the constipation and prolapsus recti. The muscular insufficiency may 
be associated with overfatness, and mask the local rachitic mani- 
festation. 

The ligaments are more or less lax allowing undue mobility at the 
larger joints, and giving rise to the abnormality known as "double 
joints." 

Coincidently with and in a measure because of the gross alterations 
in the body framework, manifold changes occur also in the functions 
and structures of other organs of the body. 

The respiratory system suffers early. The contracted chest com- 
presses its contents and disturbs the equilibrium of the thoracic and 
abdominal organs. The area of breathing space is reduced, hence, 
respiration is more or less interfered with, and the tendency to respi- 
ratory disease greatly increased. The latter is favored also by the 



510 DISEASES OF CHILDREN 

timidity of the parents to expose their delicate babies to outdoor air, 
keeping them huddled up in poorly ventilated rooms and thus reducing 
their power of resistance to infection. In consequence of this, slight 
catarrhal affections of the nasopharynx or larynx, instead of, as in 
the normal, yielding promptly to suitable treatment, they persist indefi- 
nitely and lead to capillary bronchitis or bronchopneumonia, not rarely 
with fatal issue or greatly protracted convalescence with a predisposi- 
tion to tuberculous infection. As an immediate result we have also pro- 
found secondary anemia — reduction of hemoglobin and red blood cells 
and moderate leucocytosis. The child is pale, sometimes waxy in color ; 
its digestion is poor: diarrhea alternates with constipation (often the 
feces are hard and the rectum is unable to expel the lump until 
aided by mechanical means), the latter, however, preponderating. The 
liver and spleen are more or less enlarged and help to distend the ab- 
domen, sometimes to such an extent as to greatly resemble tuberculous 
peritonitis (see p. 155). Rachitic children are very irritable, sleep rest- 
lessly, and show a great disposition toward different spasmodic condi- 
tions. Spasmus glottidis, spasmus nutans, eclampsia and tetany are 
frequent complications of severe and protracted cases of rickets, es- 
pecially in very young infants. 

Cases of rickets presenting the local and general symptoms here de- 
picted usually offer no diagnostic difficulties. Less typical cases, how- 
ever, may be confounded with cretinism, achondroplasia, congenital 
syphilis, incipient hydrocephalus, and osteogenesis imperfecta— a group 
of diseases which not only have several symptoms in common and are 
to a certain extent etiologically correlated, but may also be associated 
with rickets. 

In cretinism there is marked mental deficiency; the tongue thick and 
protruding from the mouth; as the child grows older there is very pro- 
nounced disparity between its age and body length. 

Achondroplasia is characterized by a striking disproportion between 
the length of the trunk and extremities; the curvature of the shafts 
of the bones is due to embryonic defective development and not, as in 
rickets, to softness of the bones; the fingers do not lie parallel as in the 
normal, but are spread out like ribs of an open fan. 

The epiphyseal thickening at the ribs and the long bones of syphilis 
hereditaria, as a rule is observed soon after birth in association with 
other symptoms of syphilis which yield promptly to specific treatment. 

Incipient hydrocephalus has several symptoms in common with 
rickets (separation of the fontanelles, softening of the cranial bones, 
irritability of the nerve system). In hydrocephalus, however, the 
cranial distention is rapidly progressive in character, leaving the long 
bones of the body, which suffer most in rickets, almost unmolested. 



DISTURBANCES OF METABOLISM 511 

Osteogenesis imperfecta differs from rickets in that in the former 
the bones are so soft that they can be cut and bent, splintered and 
fractured in several places. 

The importance of an early diagnosis cannot be too strongly em- 
phasized, since upon it depends the prognosis and the success of the 
treatment. While it is generally admitted that rachitis per se is not 
dangerous to life, and that in a number of cases spontaneous recovery 
is possible, the indifference of the laity as well as the physician re- 
garding early and persistent treatment is strongly to be deprecated. 
Spontaneous recovery is rarely complete. On the contrary, without 
suitable treatment, the majority of children are left stunted in growth, 
distorted in shape and features, and depressed in spirit — in short, 
poorly qualified to struggle for an existence and to compete with the 
fellowmen favored by good fortune with sound mind and body. 

Treatment. — Rickets is preventable by abundance of sunlight and 
fresh air and by a mixed, nutritious diet. In the absence of contra- 
indications, children over three months of age should receive in addi- 
tion to milk, small quantities of carbohydrates and orange juice; those 
over six months, also thin meat and vegetable soups; those over nine 
months, half of or a whole soft-boiled egg, some beef juice, and a 
little toasted bread with sweet butter; and those over a year, one 
egg daily, some thick fresh vegetable soup, with finely scraped beef or 
chicken, oatmeal gruel, light cocoa, etc., and occasionally a small 
quantity of finely scraped fresh beef spread on bread or mixed with 
baked potato. Season permitting, raw milk should be given in pref- 
erence to boiled, sterilized or pasteurized. 

Rachitic deformities may be prevented by avoiding superencum- 
brance of the spine and extremities. Infants with incipient rickets 
should, as much as possible, be kept off their feet, and advantageously 
held in the recumbent posture, allowing them to remain in the upright 
position only for short periods at a time. 

The suggestions just made apply as well to the management of fur- 
ther advanced cases of rickets. Here, too, sunshine and nitrogenous 
diet in abundance and removal of the superincumbent weight of the 
body are the remedies par excellence. To these we should add hydro- 
therapy (sea salt baths), massage and passive motion, and corrective 
light braces where the deformities persist. Operative corrective pro- 
cedures should be reserved for deformities of over three years' stand- 
ing, since slight curvatures usually respond to nonoperative antirachi- 
tic measures. 

As auxiliaries, especially with the view of overcoming the anemia 
and the deficiency of mineral elements, the syrupus calcii et sodii 
hypophosphitum (N. F.), the syrupus hypophosphitum compositus (U. 



512 



DISEASES OF CHILDREN 



S. P.), the syrupus ferri iodidi and the liquor pliosphori (N. F.) are of 
great therapeutic value. However, cod liver oil is the specific in rachitis 
and may advantageously be combined with the aforementioned remedies. 
(See p. 451.) 

In intractable cases organotherapy, especially the extracts of thy- 
roid, thymus, and pituitary glands and red bone marrow should be 
given a fair trial. A sojourn at the seashore is highly to be recom- 
mended. Cases of florid rachitis of older children up to ten years of 
age are on record. They are usually spoken of as rachitis tarda, 

Achondroplasia* 

(Chondrodystrophia Fetalis, Fetal Rickets, Micromelia) 

These terms are used to designate a peculiar type of congenital 
dwarfism arising from early fetal arrest of growth of the bones that 




Fig. 148. — Achondroplasia in ten-month-old baby. Note great length of trunk as 
compared with the short extremities. 



*Though not an acquired disease, this subject is treated here in order to emphasize its 
many differences from rickets. 



DISTURBANCES OF METABOLISM 



513 



are formed in cartilage, leaving the bones that are laid down in mem- 
brane unaffected. Thus, we have shortening of the extremities, and of 
the bones of the base of the skull, while the bones of the vault of 
the cranium and the trunk are normal. This peculiar chondral dys- 
trophy produces the following characteristic statural disparities : 




Fig. 149. — Achondroplasia (left). Both children are of the same age. Note the 
short legs and long trunk in the achondroplasiac as compared with the normal 
(right) child. (After Drs. Wood and Hewlett.) 



Shortness of the extremities as compared with the normal (relatively 
long) abdomen ; the forearms are longer than the arms and the legs longer 
than the thighs; bowing of the extremities, especially lower, and 
thickening of the terminal epiphyses; limited pow r er of extension of 
the upper extremities; peculiar fan-like divergence of the thick, uni- 



514 DISEASES OF CHILDREN 

formly sized fingers, the so-called "trident hand"; marked narrowing 
of the pelvis; lordosis; protuberant abdomen; narrowing of the base 
of the skull ("pug-nose," broadening of the jaws) as compared with 
the normal (relatively large) upper part of the skull. The skin and 
nails are normal ; the hair is soft and abundant in growth. Intellect is 
usually fairly normal. The great majority of cases of achondroplasia 
die in utero or soon after birth. Those who survive may attain old 
age. They very rarely exceed 4 feet in height. 

Scorbutus Infantum 

(Moeller-Barlow's Disease, Scurvy, Acute Rickets) 
Infantile scurvy is an acute specific hemorrhagic affection of as yet 
unknown origin. It is probably due to direct microbic infection or 
toxemia resulting from intestinal putrefaction. As the disease oc- 
curs principally in infants from six to eighteen months old, the 
period when nutritional disturbances are most rampant, there is every 
reason to believe that malnutrition is the most active predisposing 
cause. This explains also the frequency with which infantile scurvy 
is observed in infants fed exclusively on boiled or sterilized milk 
(milk deprived of some of its nutritious qualities), or poor breast 
milk, in short, on food lacking some essential elements (vit amines*). 
I had the opportunity to observe scurvy in a pair of twins six and 
a half months old, who were partly breast fed. The disease developed 
in both of them almost at the same time, and subsided promptly on the 
administration of small quantities of lemon juice, mixed vegetable 
soups and raw milk in addition to the breast feeding. The simultan- 
eous occurrence of the affection in both babies and the absence of a 
history of faulty feeding tend to the infectious theory of the causation 
of scurvy. The principal pathologic changes in scurvy consist of an 
increase in the width and vascularization of the cartilage zone and 
hemorrhage into the loose vascular layer of the connective tissue of the 
periosteum adjacent to the bone, thus leading to detachment of the 
periosteum from the bone and forming a thick sheath of blood clot 
underneath it. The lower and upper extremities and the ribs are most 
frequently affected. Hemorrhages take place also in the mucous 
membranes of the hard palate and gums, in the muscles and more 
rarely in the serous cavities and solid viscera. There is anemia but no 
leucocytosis. The calcium content of the blood is decidedly diminished 
(Hess)*. 

The onset of the disease is usually sudden or, less frequently, pre- 
ceded by malaise or digestive disturbance of a few days' duration 

*See p. 114. 



DISTURBANCES OF METABOLISM 



515 



and slight fever. The child is restless, cries when it tries to move 
itself or when it is being handled. This symptom is the result of 
pain and tenderness especially in the lower extremities. For fear 
of pain the patient instinctively ceases to move its limbs (pseudoparaly- 
sis). Examination of the extremities soon reveals at the diaphyses of 
one or both femurs, more rarely of the tibia and fibula, or upper 
limbs, spindle-shaped, colorless, smooth, nomiuetuating swellings sur- 
rounding the bones. The tumefactions for the most part are due to 
subperiosteal hemorrhage. Exceptionally there is bleeding also from 




Fig. 150. 



-Scorbutus in a fifteen-months-old infant. Xote hemorrhage from the gums 
and in the skin, and swelling of lower extremities. 



beneath the periosteum of the ribs and of the bones of the head (pro- 
trusion of the eyeball in subperiosteal hemorrhage of the frontal bone) 
and face, and occasionally spontaneous separation of the epiphysis 
from the shaft of the bone, leading to bone infraction, impaction or 
fracture. The next important symptom of infantile scurvy is spongi- 
ness and discoloration (minute transient ecchymoses) of the gums, 



516 DISEASES OF CHILDREN 

with a tendency to bleed. In quite a number of cases the hemor- 
rhagic tendency extends also to the skin, subcutaneous tissue (typical 
"black eye" after a fit of crying or laughing, also discoloration and 
proptosis of an eye resembling that of chloroma), to the mucous mem- 
branes and the viscera (dysentery!), so that as a result of loss of 
blood profound anemia, edema and albuminuria supervene. On the 
other hand, some cases pursue a very mild course (formes frustes), es- 
pecially if recognized early and treated energetically. Except occa- 
sional permanent hyperostosis of the affected shafts of the extremities, 
the prognosis as a whole is favorable, recovery usually taking place 
within from a few weeks to as many months. Neglected cases, how- 
ever, may end fatally from the aforementioned complications, or from 
pneumonia. 

Treatment. — An antiscorbutic diet and fresh air form the treatment 
par excellence. Prompt improvement and rapid recovery usually fol- 
low the administration of fresh cow's milk, fresh fruit juice (lemon, 
orange, or pineapple), fresh vegetable soups, beef juice, and in older 
children fresh eggs and vegetables (potato puree, carrots, tomatoes, 
fresh or canned — Hess — spinach, etc.). Where convalescence is pro- 
tracted we may prescribe the compound syrup of hypophosphites 
(U.S.P.) with extract of malt and cod liver oil. 

Infantile scurvy may be mistaken for rheumatism, peliosis rheu- 
matica, purpura hemorrhagica, syphilitic epiphysitis, osteomyelitis, 
rickets, and occasionally (when the orbit is involved) for chloroma. 

In rheumatism the swelling is usually localized at the articulations 
and "jumps" from one place to another. It is accompanied by fever 
and responds to the salicylates. Hemorrhages are absent. 

Peliosis rheumatica is characterized by deep red or bluish spots, as 
a rule, limited to the extremities. It usually occurs in older children. 

Purpura hemorrhagica is free from diaphyseal hematomas and pain. 

Syphilitic epiphysitis is free from the hemorrhagic tendency, and 
often presents other syphilitic lesions. 

Osteomyelitis is associated with high fever and rapid local suppura- 
tion. 

Rickets is free from acute pain and hemorrhagic symptoms, but 
has other pathognomonic symptoms. It responds very slowly to treat- 
ment. It is worth remembering, however, that rickets and scurvy 
may coexist. 

Chloroma or green tumor usually shows a predilection for the skull 
(temporal fossae and orbits), giving the child a characteristic frog-like 



DISTURBANCES OF METABOLISM 517 

appearance. It is a grave blood disease — profound anemia with rel- 
ative and absolute increase in lymphocytes. 

Beriberi 

(Kakke. Polyneuritis Endemica) 

There is still considerable diversity of opinion regarding the etiology 
of beriberi. While the majority of observers attribute the disease to 
a polished-rice-diet, to an insufficiency in vitamines,f some clinicians 
believe it to be due to an unknown infectious agent. Beriberi prevails 
extensively in Japan, China, Indo-China, Borneo, Philippine Islands, 
Straits Settlements, Malay States, Java and Sumatra, Brazil and Ice- 
land. 

It ordinarily runs an afebrile course, developing insidiously with 
epigastric pain, debility, sensation of precordial oppression and other 
symptoms of dilatation of the heart. Physical examination elicits, 
weakness of the extremities, hobbling gait with the legs widely apart: 
immobility to stand with the eyes shut, wasting of the anterior 
tibial and peroneal muscles, loss of knee jerks, preceded by exaggera- 
tion; later also wrist drop, and edema, especially of the lower ex- 
tremities, in the absence of other signs of nephritis. Sometimes the 
disease runs an acute course with paralysis spreading to the respira- 
tory muscles, when it usually proves fatal. Otherwise the mortality 
ranges between from 5 to 50 per cent, all depending upon how early 
the treatment is initiated. 

Treatment. — Rest in bed, nutritious diet (fresh milk, fresh fruit and 
and vegetables, meat broths and juice, unpolished rice and other ce- 
reals), autolyzed yeast* (5 to 30 drops t. i. d.), tonics, such as iron, 
quinine and strychnine and sometimes digitalis in cases of heart weak- 
ness. 

Pellagra 

This disease is not rarely met with in this country, especially in 
the south. Its cause is still the subject of considerable controversy. 
Some clinicians 1 attribute it to a vegetarian diet,f with a preponderance 
of cereals, others 2 maintain that it is an insect-borne infection, since 
it prevails during the summer and early autumn, when certain gnats 
of the genus Simulium abound. It may readily be assumed that while 



fSee page 114. 

*Dry pressed brewer's yeast is placed in an incubator at a temperature of 37.5° C. for 32 
hours; the liquid is allowed to gravitate through a paper filter and then kept at room temperature 
for another 10 hours until the purin bodies have separated when it is again filtered. The auto- 
lyzed yeast if kept on ice will not spoil for quite a long time. It is not to be used if mould forms. 

iGoldberger, Wheeler and Lydenstricker (Jour. A. M. A., September 21, 1918). 

gobbling and Petersen (Jour. Infect. Dis., Vol. 18). 



518 DISEASES OF CHILDREN 

an infection is the exciting cause of the disease, a deficiency of fresh 
green vegetables and animal protein in the dietary serves as the most im- 
portant predisposing cause. 

Pellagra is characterized by symmetrical erythema or dermatitis, 
chiefly on the exposed surfaces (neck, face and extremities), red, As- 
sured tongue, diarrhea or constipation, restlessness, insomnia, pares- 
thesia, and disturbance of the knee jerks (either exaggerated or ab- 
sent). 

It is readily curable by change of climate, restriction of cereals, and 
feeding on animal proteins, such as fresh milk, beef juice, broths, eggs, 
meats, etc., also fresh fruits. Hematic tonics. The skin should be pro- 
tected from the rays of the sun, and the eruptions treated with calamine 
lotion and similar mild remedies. 

Diabetes Mellitus 
(Glycosuria) 

Within recent years, with increased interest in accurate diagnosis, 
the number of cases of diabetes in children recorded has greatly in- 
creased. In former years undoubtedly many of the rapidly fatal 
cases escaped observation. The importance of careful examination 
of the urine of older children and infants suffering from polyuria or 
enuresis, therefore, cannot too strongly be emphasized. 

We distinguish two forms of glycosuria : glycosuria spuria, (tem- 
porary or dietetic), and glycosuria vera (diabetes mellitus). The 
first variety is comparatively of little clinical importance. It is the 
result of consumption of sugar greater in quantity than can be assim- 
ilated, and usually disappears after arrest of the causal factor. 

On the other hand, diabetes mellitus is an extremely fatal affection, 
death taking place, in violent cases, sometimes after a few weeks or 
months, or in less acute cases, often within a year or two at the latest. 
This variety is often hereditary. 

The onset of diabetes mellitus is rather sudden. The child begins 
rapidly to lose in weight, notwithstanding good appetite, suffers from 
excessive thirst, passes a large quantity (75 to 115 ounces) of urine 
(often enuresis nocturna as well as diurna!), of high specific gravity 
(1,030), containing a large proportion of sugar, at times acetone and 
diacetic acid, and loses in vitality from day to day. In addition to these 
symptoms there are also digestive disturbances, dryness of the skin, skin 
affections (furunculosis, lichen-like eruption with severe itching) onychi- 
tis, cataract, nerve disorders (e. g., Friedreich's ataxia), obstinate acetone 
odor from the mouth, etc. The course of the disease varies. As a rule, it 



DISTURBANCES OF METABOLISM 



519 



is more rapid than in adults ; the younger the patient the more violent the 
course. Death usually occurs as a result of general exhaustion or in- 
tercurrent diseases, such as pneumonia, tuberculosis, and the like. 
and is frequently preceded by coma diabeticum or uremia. Recov- 
eries, however, are also on record. 

Treatment. — Every effort should be made to trace the cause of the 
disease and to combat it energetically. As congenital or acquired 
syphilis has frequently been found to play an essential part in the 
causation of diabetes, it is prudent to subject the patient to a 
course of antisyphilitic treatment. We have no means at our com- 
mand to influence the other supposed etiologic factors of diabetes, 
such as traumatism to the head, shock, tuberculosis, various infec- 
tious diseases, etc. The time is not distant, however, when the true 
nature of the affection will be disclosed, and the remedies found which 
will greatly aid us in the prevention and arrest of the disease at 
its very inception. Until this blissful moment arrives we will have 
to continue groping in the dark, empirically treat symptoms, and de- 
pend, chiefly upon a restricted diet, which at best never strikes the 
root of the evil, and is hardly practicable in diabetes of early child- 
hood. Wherever possible especially in older children i, the diet should 
consist of fresh meat soups and broths ; bread and biscuits of gluten 
flour, with cream and butter ; eggs ; moderate quantities of meats of all 



FOODS ABBAXGED ACCORDING- TO THEIE APPEOXIM 
OF CAEBOHYDBATES (E>B. HALEEBX 
(1) 5<% 
Fresh Vegetables: 

Lettuce Tomatoes 
Spinach Bhubarb 
Sauerkraut Leeks 
String beans 
Celery Egg plant 
Asparagus Cabbage 
Cucumbers Badishes 
Brussels sprouts 
Sorrel Beet greens 
Endive Water cress 
Dandelion greens 
Swiss chard 

Pumpkin 
Sea kale Kohlrabi 
Broecali 

Vegetable marrow 
Cauliflower 

Canned Vegetables: 

Asparagus 
Spinach 
String beans 



ATE PERCENTAGE 



Fruits : 


Gooseberries 


Currants 


Eipe olives 


Peaches 


Easpberries 


Grape fruit 


Pineapple 


Huckleberries 


Nuts: 


Watermelon 


Nuts: 


Butternuts 


Nuts: 


Almonds 


Pignolias 


Brazil 


English walnuts 


Miscellaneous: 


Black walnuts 


Beechnuts 


Unsweetened & un- 


Hickory 


Pistachio 


spiced pickles, — 


Pecan 


Pine 


clams, fish, oy- 


Filbert 


(4) 20o/ o 


sters, scallops, liv- 


(3) 15% 


Fresh Vegetables: 


er, roe. 


Fresh Vegetables: 


Potatoes 


(2) 10% 


n 


Shell beans 


Fresh Vegetables: 
Onions Carrots 


u-reen peas 
Artichokes 


Baked beans 
Green corn 


Squash Okra 


Parsnips 


Boiled rice 


j Turnips Beets 


Canned Vegetables: 


Boiled macaroni 


Mushrooms 


Lima beans 


Fruits: 


Fruits : 


Fruits: 


Plums Bananas 


Lemons 


Apples 




Oranges 


Pears 


Nuts: 


Cranberries 


Apricots 


Peanuts 


Strawberries 


Cherries 


(5) 40% 


Blackberries 


Blueberries 


Chestnuts 



520 DISEASES OF CHILDREN 

kinds, and fish, oysters and scallops; well boiled spinach, asparagus, 
string' beans, cauliflower, cabbage, radishes, and turnips; protein milk; 
fresh sour fruit, such as grapefruit, lemon, occasionally cranberries and 
blackberries. Saccharin instead of sugar. In infants milk and amylacea 
are indispensable, but should be restricted as much as possible. Oatmeal 
gruel seems to work well in some cases. Mild hydrotherapeutic pro- 
cedures, and light exercise are useful. Bicarbonate of soda in large 
doses should be administered to prevent acidosis. Opium, in some 
form, and arsenic, in addition to cod liver oil and iron, are the only 
drugs of therapeutic value. Complications should be treated accord- 
ing to indications. Koplik is of the opinion that the Allen treat- 
ment of fasting, as employed in adults, is also applicable in children. 
During the treatment the child should be kept in bed. 

Diabetes Insipidus 
(Polyuria) 

Polyuria, like glycosuria, may be transient or persistent. Transient 
polyuria is quite common in children and is usually of nervous origin. 
On the other hand, persistent polyuria — diabetes insipidus — is compar- 
atively rare. It is manifested by excessive thirst, polyuria (pale, 
sugar-free urine of low specific gravity, not exceeding 1,006), dry 
skin, disturbances of the digestive and nervous systems. The course 
is very protracted, but the prognosis quoad vitam favorable. Perma- 
nent recovery is rare. 

As the etiology is obscure (disease of the hypophysis cerebri?), little 
can be expected from treatment except in cases due to syphilis which 
frequently yield to antisyphilitic medication. Change of air, hydro- 
therapy, a nitrogenous diet and an ample supply of water act bene- 
ficially. 

A number of clinicians have lately been recommending pituitary 
solution (posterior lobe) in doses of from 0.25 to 1 c.c. subcutaneously 
and also by mouth. The output of urine is reduced, but only tem- 
porarily. 

Adipositas 

(Lipomatosis Universalis, Obesity) 

Contrary to what is observed in older children or adults, overfatness 
in infants very rarely gives rise to constitutional disturbances. As a 
rule, the fatness subsides when the child begins to walk about. 

In older children obesity is often associated with marked anemia, 
shortness of breath and fatty degeneration of the heart. If such symp- 



DISTURBANCES OF METABOLISM 



521 




Fig. 151.— Adipositas; child weighs thirty-six pounds at eight months. 

toms appear, it is essential to eliminate fats and carbohydrates from the 
dietary and to recommend systematic exercise, active massage, and hydro- 
pathic procedures. Carlsbad salts and thyroid gland substance are of- 
ten useful ; some cases, however, resist all sorts of treatment, and readily 
succumb to intercurrent diseases. 

Adipositas should not be mistaken for cretinism (q. v.) and Frolich's 
Syndrome (q.v.). 

Exudative Diathesis 

This symptom complex, first fully elucidated by Czerny, is quite fre- 
quently observed in infants of certain predisposed families. It does 
not seem to be congenital in nature although some clinicians claim to 
recognize the diathesis in the newborn by a prominent comb-shaped tuft 
of hair in the centre of the scalp. The affection is characterized by 
the combination of inflammatory symptoms of the skin and mucous 
membranes, as follows: (1) The skin: transient erythema, intertrigo, 
urticaria, prurigo, blepharitis, phlyctenular conjunctivitis, and sebor- 
rheic eczema; (2) the respiratory tract; recurrent angina, pharyn- 
gitis, coryza, laryngitis diffuse bronchitis and tendency to asthma; (3) 
the alimentary tract : stomatitis, lingua geographica, unprovoked diar- 



522 DISEASES OP CHILDREN 

rhea and mucous colitis. Excepting the presence of marked eosinophi- 
lia (from 10 to 20 per cent), the blood shoves no definite alterations. 
The nervous system is but slightly involved (vasomotor disturbance, 
as manifested by transient flushing of the face). Some authors attrib- 
ute pavor nocturnus, spasmophilia and incontinentia urinae to the 
exudative diathesis. The general appearance of the baby may vary 
from puniness to obesity, in either case accompanied by muscular 
atony and general lymphatic enlargement. 

Czerny attributes the condition to faulty food assimilation, partic- 
ularly of fat, giving rise to endogenous nutritional noxa and conse- 
quent increased susceptibility to local infections, and anaphylaxis. 
It is also caused by ectogenic nutritional noxa, resulting from over- 
feeding by a rich diet, be it proteins, fats or carbohydrates. In some 
cases the food idiosyncrasy may be determined by the ''Allergy test." 
(See p. 87.) 

Treatment. — This must be directed principally to the suitable se- 
lection of the dietary. The supply of milk, even to the very young 
infant, must be limited to the bare necessity of life, paying particular 
attention to elimination of fat. The milk at all times should be diluted 
with cereal gruels. Older babies should be fed on cereals, well-boiled 
vegetables and bread, and but little milk. Fruit, raw or cooked, is al- 
lowed. Careful attention should be paid to the nose and throat, and to 
the skin. Outdoor air, preferably in the country. 

Acidosis 

(Recurrent, Cyclic, Periodic, Vomiting. "Acid Intoxication") 

Cautley defines acidosis as "an abnormal metabolism of carbon, lead- 
ing to the appearance of organic acids in the blood and urine, and the 
formation of ammonia to neutralize the acids." The chief evidences of 
acidosis are the presence of acetone bodies (acetone, diacetic acid, 
beta-oxybutyric acid) in the urine, diminished alkalinity of the blood 
(as readily determined by the phenolsulphonephthalein test) and reduced 
C0 2 tension* in the alveolar air (tested by the Plesch-Howland appara- 
tus). It is well to remember, however, that the presence of acetone bodies 
in the urine is not pathognomonic of acidosis alone, since they are not 
rarely observed in acute febrile diseases, starvation and cachexia, acute 
yellow atrophy of the liver, and delayed anesthesia poisoning. The 
cause of acidosis is still awaiting definite solution. Ewing suggests 
that acidosis is due to disturbance of fat metabolism, caused by de- 



*Normal tension is about 45 mm. Hg., equaling 6 per cent CO2; anything below 30 mm. is an 
indication of acidosis. 



DISTURBANCES OF METABOLISM 523 

ficient hepatic function associated with the absorption of alimentary 
toxins. Mellanby believes acidosis to be caused by derangement of 
the glycogen function of the liver, leading to imperfect metabolism of 
the fats with formation of the aforementioned acids as intermediary 
products and imperfect protein metabolism and creatin formation due 
to carbohydrate insufficiency. In view of the fact that acidosis has 
occasionally been met in epidemic form, some authors are inclined to 
attribute it to an obscure systemic infection or a species of toxemia. 
According to C. H. Dunn, acidosis prevailed around Boston in the 
winter of 1915 and 1916, but he thinks it was symptomatic of a grip- 
like infection of the upper air passages. 

Acidosis is most common in children from two to five years old. It 
is manifested clinically by sudden attacks of vomiting, anuria, pros- 
tration, sopor, and hyperpnea. The respirations may reach up to sixty 
per minute, yet be free from dyspnea and cyanosis (the patient's lips 
are usually deep red in color). The vomiting recurs, periodically, 
cyclically, at short or long intervals, is incessant and uncontrollable, 
often blood and bile stained, and occasionally so intense as to pro- 
duce alarming hemorrhage from the stomach. The vomitus in the 
beginning has a "sweetish" odor. The attacks may last from a few 
hours to several days, and abruptly end in perfect recovery of the 
patient or, exceptionally, lead to a fatal issue, particularly if not prop- 
erly handled. The temperature is moderate (except when the acido- 
sis is complicated by pyelitis which is not rarely the case especially in 
girls) ; the pulse at first somewhat retarded, and the blood shows a 
marked leucocytosis. Often the lips are bright red. 

With these symptoms in view there ought to be no difficulty to ar- 
rive at a correct diagnosis. It may, however, be mistaken for appen- 
dicitis, recurrent uremia from chronic nephritis, and tuberculous men- 
ingitis, all of which diseases of course have pathognomonic symptoms 
of their own. 

Treatment. — After brisk catharsis (calomel gr. ii), stop all liquids by 
mouth. An attempt may be made to give bicarbonate of soda in 10 
grain-doses (by putting it dry on the tongue and letting it melt in 
the mouth) every hour or two, to counteract the acidity, but if it is 
promptly rejected, it is best left alone, and administered by rectum 
instead (1 ounce of bicarbonate of soda in 1 pint of warm water). The 
irrigation should be repeated every four hours and followed half an 
hour later by nutrient enemas consisting of a 5 per cent dextrose so- 
lution, 4 ounces at a time. If dextrose is not obtainable, saccharose may 
be used instead. Occasionally, we may succeed in arresting the vomit- 
ing by administering % 6 grain of codeine sulphate (without water) 



524 DISEASES OF CHILDREN 

every four hours. Hot moist packs to induce diaphoresis often act 
beneficially. After the vomiting has ceased for about twelve hours, 
we may begin feeding b}^ mouth, giving a teaspoonful to a tablespoon- 
ful of the dextrose solution every two hours ; later zwieback, soda bis- 
cuits, or toast, cereals with small quantities of skimmed milk, and 
gradually resume the regular diet. During the intervals between the at- 
tacks, overfeeding should be avoided and the use of fats restricted. 

Test for Acetone and Diacetic Acid. — Test solution consists of 10 
grams glacial acetic and 10 c.c. of 1:10 solution of sodium ' nitro- 
prusside. Add 20 drops of this reagent to 15 c.c. of filtered urine in 
a test tube. Overlay the mixture with ammonia water. The presence 
of acetone, even 1 part in 2,000, causes a purple ring at the surface, 
separating the two fluids. Dilute urine with 4 parts of water, add 
drop by drop solution of ferric chloride diluted 1:10. Normal urine 
or that containing acetone will show a cloudy white precipitate. Presence 
of diacetic acid, even 1/10,000, gives a purplish black cloudy precipitate. 



CHAPTER IX 

DISEASES OF THE CIRCULATORY SYSTEM 

CONGENITAL HEART DISEASE 

(Vitium Cordis) 

As a rule, infants born with heart disease are very delicate. Most 
of them are born asphyxiated and if resuscitated remain cyanotic, 1 
or very anemic, atelectatic, cry feebly, breathe superficially and very rap- 




Fig-. 152. — Vitium cordis. "Morbus cceruleus." Note " club-shaped " fingers 
and cyanosis (represented by dark patches on face and lips), in a child eight years 
old. 



1 From_time immemorial cyanosis (morbus coeruleus or "blue sickness") has been looked upon 
as a cardinal symptom of congenital heart disease. It is usually associated with clubbing of the 
fingers and toes. Its diagnostic importance has been greatly exaggerated, since it is not rarely 
absent in the severest forms of congenital vitium cordis. 

525 



526 DISEASES OF CHILDREN 

idly, are barely able to suckle, present a very weak pulse and subnormal 
temperature. Not rarely they are born prematurely* and with congenital 
defects of other parts of the body. Some children present a club-shaped 
appearance of the fingers and toes at an early age; some of them later. 
If they survive for any length of time, their growth and development 
are very much delayed. They are helpless, begin to hold up the 
head or sit up at a much later age than the normal baby. When they 
start to walk they tire very rapidly. They rarely creep and when on 
the floor are often unable to lift themselves. They are very suscep- 
tible to colds, and once taken sick, they are very slow to recuperate. 
Bottle-fed babies frequently succumb to gastrointestinal diseases, even 
of comparatively simple nature. If they live up to school age and 
are more frequently exposed to acute contagious and infectious dis- 
eases, their weakened constitution forms a favorable nidus for the 
contraction of these affections, and is rarely able to withstand them. 

Even under the best of care, children with congenital heart disease 
usually live but a few years. Death sometimes occurs suddenly, or 
incidentally in the course of other diseases which in normal children 
are not dangerous to life, especially respiratory affections. Unless 
the heart defect is very mild in nature, children with vitium cordis 
rarely survive the age of puberty. 

The course of congenital heart disease varies, of course, with the se- 
verity of the defect, but practically resembles that of acquired vitium 
cordis, which is fully described in other parts of this treatise^ The 
following are the most common congenital heart affections. 

Persistence of the Foramen Ovale 

This condition is the result either of faulty construction of the fora- 
men or its valves, or defects in other portions of the heart (e. g., steno- 
sis of the pulmonary artery) which by indirect blood pressure prevent 
complete obliteration of the foramen. 

It is the most frequent kind of congenital heart disease, but is not al- 
ways recognizable during life. In the presence of clinical symptoms 
the diagnosis may be based upon preponderance of cyanosis, a sys- 
tolic blowing sound at the base of the heart or over the third or fourth 
costal cartilage. 

Persistence of the Ductus Arteriosus Botalli 

Complete obliteration of this duct is supposed to occur by the end 
of the third month. This may be retarded or may entirely fail — 

*See "Feeble Vitality of the Newborn," p. 213. 



DISEASES OF THE CIRCULATORY SYSTEM 527 

usually in cases where the left ventricle is not properly filled with 
each heart cycle {e.g., in atelectasis, fetal pneumonia, stenosis of the 
pulmonary artery), in which event the blood from the pulmonary ar- 
tery continues to flow through the ductus arteriosus to the insufficiently 
filled aorta. As a result of this anomaly there develops sooner or 
later hypertrophy of the right ventricle usually with dilatation of the 
pulmonary artery. 

The symptomatology is very variable. In cases of only partial pa- 
tency the symptoms may be so slight as to escape observation. Com- 
plete patency of the duct very gradually gives rise to the following 
group of symptoms: disposition to respiratory affections, cyanosis, 
or waxy pallor, dyspnea, cool extremities, palpitation, a thrill over the 
anterior chest wall, increased cardiac dulness to the right, accentua- 
tion of the second pulmonic sound which can also be heard in the 
carotids, loud, buzzing, systolic murmur over the precordium, often 
epistaxis or hemorrhage from other mucous membranes, and finally, 
sometimes not until after several years of existence, marked symptoms 
of failure of compensation with rapid fatal determination. 

Defects in the Septum Ventriculorum 

(Communication of the Ventricles) 

It is a very common condition, most frequently the result of fetal 
myocardial diseased processes, and not rarely coexisting with con- 
genital stenosis of the pulmonary artery. The defect is situated either 
in the anterior or posterior portion of the septum. Very rarely the 
whole wall between the ventricles and auricles is absent, so that all 
four heart cavities communicate. 

Accentuation of the second pulmonic sound ; overfilling of the veins ; 
marked cyanosis developing soon after birth or, more gradually, some- 
time after; and hypertrophy and dilatation of the right ventricle, all 
point to a defect of the ventricular septum. A positive diagnosis, how- 
ever, is almost impossible during the life of the patient. 

The prognosis is very bad. 

Congenital Stenosis of the Pulmonary Artery 

The stenosis may involve the orifice alone, the entire trunk, or the 
branches of the pulmonary artery. Accordingly the symptomatology 
varies with the extent and location of the lesion. As a rule, there is 
marked cyanosis from birth. Some children are born asphyxiated, and 
if resuscitated, continue to suffer from attacks of suffocation and con- 
vulsions, to which they usually succumb within the first few clays 



528 DISEASES OF CHILDREN 

of life. Stronger children may survive these attacks, gain some 
strength, lose part of the cyanosis and live several years. 

Physical examination reveals arching of the anterior left chest vail, 
enlargement of the cardiac area, chiefly to the right, a diffuse systolic 
murmur, heard loudest over the left and third costal cartilages, and 
often a purring thrill on palpation. The blood usually shows a marked 
increase in the number of erythrocytes and a high hemoglobin index. 

Congenital Stenosis of the Tricuspid Valve 

It is usually the result of an anomalous or excessive development of 
the muscle substance of the valve, or of fetal endocarditis, and is often 
associated with other congenital heart defects. 

The symptomatology resembles that of defects of the pulmonary 
artery, except that the murmur is heard loudest over the fourth and 
fifth costal cartilages, and hypertrophy of the right side is either 
absent or very slight. 

The prognosis is unfavorable. 

Congenital Stenosis of the Ostium Atrioventriculare Sinistrum 

(Stenosis of the Aorta) 

The stenosis may be situated at the point of origin of the aorta; at 
any place throughout the entire aortic system; or at the ductus JBotalli. 

As a result of either one of the aforementioned conditions there is 
hypertrophy of the left heart. Varying with the seat of the atresia, 
the blood vessels above the lesion may be abnormally filled with blood, 
while those emerging below the lesion suffer from a deficiency of it. 
Between the two groups of vessels a collateral circulation is usually 
established which may frequently be recognized by numerous, visible, 
actively pulsating, subcutaneous blood vessels over the thorax. A sys- 
tolic murmur is often heard over the dilated arteries. The heart is 
usually free from any auscultatory signs, unless the orifice of the aorta 
be involved, when a loud systolic murmur may be heard at midsternum. 

The patient may live for several years — until compensation rup- 
tures. Death sometimes ensues very suddenly from rupture of a group 
of vessels above the stenosis. 

Treatment.— The treatment of congenital heart disease is practically 
the same as that of acquired and is fully outlined on p. 540. Complete 
rest in the strictest sense of the word will help to prolong life — possi- 
ly to an advanced age. 



DISEASES OF THE CIRCULATORY SYSTEM 



529 



Dextrocardia 

Among the few congenital malpositions of the heart (mesocardia — 
the heart occupies a central position of the chest wall ; ectopia cordis — 
the heart may be situated either between a fissure in the sternum im- 
mediately beneath the skin, in the neck or in the abdomen below the 
diaphragm), dextrocardia (see Fig. 153), or transposition of the heart 
to the right side, is of special interest inasmuch as it very rarely inter- 
feres with the life or welfare of the patient. Dextrocardia is often 
associated with a general transposition of the viscera. The aorta and 



mbiiiiii— m^mmm 



Fig. 153. — Dextrocardia in a girl six years old. Posterior view. 

its branches usually remain in their normal situation. Dextrocardia 
should not be confounded with displacement of the heart by large ef- 
fusions or growths in the thoracic cavity. 



ACQUIRED HEART DISEASE 

Myocarditis 

Degeneration of the muscular tissue of the heart is occasionally 
congenital, a sequel of infection during fetal life, but most frequently 
acquired, occurring either secondarily to acute infectious diseases, or 



530 DISEASES OF CHILDREN 

as a result of extension of an inflammation of the inner or outer lining 
of the heart. 

The inflammation may be diffuse or circumscribed, and as in adults, 
either plastic or interstitial, or degenerative or parenchymatous. 

The interstitial variety of myocarditis usually leads to suppuration 
and abscess formation of the musculature. In parenchymatous myo- 
carditis the transverse striae of the fibrillae appear lost, the muscle 
consisting chiefly of fatty and granular substances. 

The course of the disease varies greatly with the underlying cause 
and the rapidity of the inflammatory process. 

In the majority of instances interstitial myocarditis is complicated 
by endocarditis and pericarditis, and hence it is very seldom possible 
early to diagnose the existence of the myocarditis. In cases where the 
inflammation is circumscribed, myocarditis may be surmised by the 
sudden precordial pain, dyspnea, high fever, restlessness and delirium. 
The apex beat and pulse are weak, arrhythmic and rapid. Death is the 
usual termination; not rarely occurring suddenly with symptoms of 
sudden collapse. 

Parenchymatous myocarditis ordinarily runs a slow and latent 
course. Occasionally, however, the degenerative process develops quite 
rapidly. Extreme pallor, breathlessness, and weak and galloping pulse 
point to the involvement of the myocardium, but in the early stages 
the diagnosis can rarely be made with any degree of certainty. As 
the disease advances and symptoms of cardiac dilatation and passive 
pulmonary congestion set in, the diagnosis is fairly certain. 

The treatment is the same as in endocarditis (q.v.) 

Pericarditis 

Primary pericarditis is usually due to a streptococcus or pneumococcus 
infection through the blood or lymph channels or in connection with 
acute articular rheumatism. Like pleuritis, inflammation of the 
pericardium may occur in dry form or with an effusion. The exu- 
dation may be serofibrinous, hemorrhagic, or purulent. Dry, as 
well as exudative, pericarditis may give rise to inflammatory adhesions 
between the pericardium and the heart, and occasionally to the an- 
terior and posterior chest walls and vertebral column. 

The gravity of this affection should, therefore, not be underesti- 
mated. The prognosis is serious, especially in the secondary variety 
occurring in connection with tuberculosis, septic processes, pleuro- 
pneumonia, caries of ribs or vertebras, severe exanthematous diseases 
(e. g., scarlatina), purpura hemorrhagica, chronic nephritis, etc. It is 
less dangerous in primary, usually rheumatic form, particularly if the 



DISEASES OF THE CIRCULATORY SYSTEM 531 

patient is over three years of age, or when caused by syphilis and is de- 
tected and treated early. 

Bearing in mind the etiologic factors just enumerated, Ave can 
readily appreciate that pericarditis in children must be quite com- 
mon. Indeed, there is ample reason for the belief that in children 
over three years of age pericarditis is almost as frequent as endo- 
carditis, with which affection, by the way, it is not rarely associated. 

The onset of primary pericarditis is usually very sudden, but some- 
times, like the secondary variety, it may be insidious. Ordinarily it 
is ushered in with high temperature, vomiting, cardiac oppression, or- 
thopnea, dyspnea, and accelerated pulse. Cough is an early symptom, 
and, in the presence of an effusion, quite pronounced. This symptom 
is probably due to cardiac pressure against the lungs. The pulse, which 
in dry pericarditis is strong, is often very feeble, barely perceptible, 
and irregular in marked exudative pericarditis. Pain is frequently 
intense, especially if associated with polyarthritis. The patient is 
restless, sleepless, the expression of his face anxious, and denoting great 
suffering. Of course, the symptomatology is greatly modified by that 
of the underlying affection, if existing. 

The physical signs vary with the stage of the disease. Before the 
development of the effusion, auscultation elicits superficial, exocar- 
dial, to-and-fro friction and creaking sounds, limited over the cardiac 
region, often changeable with the position of the patient and audible 
independently of the heart sounds. Friction fremitus may be felt over 
the area where the friction murmur is heard. Endocardial murmurs 
may coexist. When serous effusion occurs the friction sound is found 
diminished or absent, the heart impulse very feeble, whereas the 
pulse may be felt quite strong, and the respiratory movements of the 
left side of the chest are diminished. The area of heart dulness is greatly 
increased laterally and vertically, pushing the edges of the lungs aside 
so that the entire sternal region is dull on percussion. When the 
effusion is large, we can also note distinct bulging of the cardiac area 
of the chest. According to Rotch, the liver is depressed and a dull 
note is obtained in the right fifth intercostal space. He considers this 
a sign of great importance in the differentiation of pericardial effusion 
from cardiac dilatation, since in a dilated heart the dulness, he thinks, 
never reaches the fifth interspace. 

There are several other distinctive features which render the dif- 
ferentiation of pericardial effusion from enlarged heart possible. Thus, 
in dilatation or hypertrophy of the left ventricle, the apex beat is felt 
at the extreme left limit of the dulness (outside the mammary line) 
and at its lowest level, while in effusion the apex beat, or rather the 



532 DISEASES OF CHILDREN 

heart impulse, is at a spot inside and above the boundaries of the car- 
diac dulness, somewhere between the fourth and third interspace. 
In pericarditis the dulness develops much more acutely than in an 
enlarged heart, which latter occurs secondarily to more or less chronic 
valvular disease. However, w T e should bear in mind that pericarditis, 
acute or chronic endocarditis, and hypertrophy and dilatation may co- 
exist and give rise to a symptom complex beyond the possibility of in- 
dividualization. For further differentiation between pericarditis and 
endocarditis the reader is referred to the discussion of the latter af- 
fection. (Seep. 536.) 

With absorption of the fluid in the pericardium there is a gradual 
return of the symptoms of the first stage and, in favorable cases, 
restitutio ad integrum, or quite frequently, supervention of pericardial 
adhesions with consecutive systolic retraction of the chest wall over the 
entire precordium. 

The nature of the effusion can readily be ascertained by exploratory 
puncture, but even without it we may surmise the presence of pus if the 
pericarditis develops secondarily to septic processes; blood, after severe 
trauma, and serum, in primary, usually rheumatic, pericarditis. An 
x-ray examination is often of service. The determination of the charac- 
ter of the effusion is important especially as regards the further course 
and treatment of the disease. 

Eheumatic pericarditis, if free from complications, lasts from two 
to three weeks or longer. After about ten days there is a gradual 
evanescence of the symptoms. Not infrequently, however, the ap- 
parent recovery is only temporary, inasmuch as there may be a return 
of the effusion, or development of valvular deposits, which sooner or 
later give rise to marked valvular disease. These manifestations are 
particularly prone to occur in pericarditis with polyarthritis. Peri- 
carditis, like endocarditis, not rarely precedes the joint symptoms, may 
run a latent course and if mild in character disappear again without 
being detected, possibly not until repeated recurrences and appear- 
ance of complications. More rarely, pericarditis ends in death either 
rapidly as a result of cardiac muscular insufficiency and pulmonary 
edema, or more slowly from early complications, such as pleurisy, pneu- 
monia, severe adhesions, endocarditis, etc. 

Purulent pericarditis pursues a much more violent course. Extreme 
fatigue, severe attacks of syncope and pyemic fever predominate, while 
the local symptoms are comparatively insignificant. Even the exuda- 
tion is often slight. When it occurs in conjunction with tuberculosis, 
it is very malignant in character. It is then manifested by enormous 
hypertrophy of the pericardium, extensive adhesions, large quantities 



DISEASES OF THE CIRCULATORY SYSTEM 533 

of pus between the heart and pericardium, and numerous tubercles 
in the latter. It is invariably fatal. The same holds true for pyemic 
pericarditis, in which streptococci, pneumococci, staphylococci and 
less frequently, gonococci act as the principal exciting cause. 

Treatment. — A disease presenting so many phases as pericarditis, 
can at best be treated only symptomatically. Absolute rest in bed, 
liquid diet (thin cereals, vegetable soups, fermented milk), an ice 
bag (not too heavy and preferably on top of a layer of lint), to the 
precordium, and sodium salicylate (1 grain for every year of the child's 
age every two hours) and codeine (% grain every six hours) inter- 
nally will often do well in rheumatic cases. In large pericardial ser- 
ous effusions with threatening syncope we may try free diuresis and 
saline catharsis with or without aspiration (in the fifth intercostal 
space a little to the left of the border of the sternum). The latter 
procedure frequently proves useful also in small nontuberculous puru- 
lent effusions, while in large purulent effusions incision and drainage 
are preferable to aspiration. In these cases some benefit may be de- 
rived from vaccines. 

In quite a number of cases sodium iodide in from 3 to 5 grain doses, 
t.i.d., seems to exert a specific effect; and, bearing in mind also the 
possibility of underlying syphilis, we should always administer this 
remedy irrespective of the variety of the pericarditis and the mode of 
treatment simultaneously employed. Digitalis or strophanthus may be 
given to strengthen the heart, if cardiac weakness sets in, which is 
apt to occur later in the course of the disease. 

Chronic pericarditis is productive of grave disturbances of the cir- 
culation, cardiac hypertrophy, and dilatation. Myocarditis is a fre- 
quent sequela. See also "Congestive Cirrhosis" and "Sugar-Cake 
Liver". 

Endocarditis Acuta 

The etiologic factors of acute endocarditis are essentially the same as 
in pericarditis (q.v.) except that the former is more frequently asso- 
ciated with rheumatic affections, such as arthritis, chorea, tonsillitis, 
erythema nodosum, etc., and not rarely complicates pericarditis. In- 
vasion of the endocardium by the streptococcus, staphylococcus, pneu- 
mococcus, the bacillus pyocyaneus, tubercle bacillus, and gonococcus 
usually occurs through the circulating blood, giving rise to a patho- 
logic condition very similar to that observed in adults. 

The inflammation, which is usually limited to the left side of the 
heart (in the fetus the right side is mostly affected), first attacks the 
vascular layer of the endocardium between the muscular and fibrous 
coats, resulting in an exudation of lymph and serum principally be- 



534 



DISEASES OF CHILDREN 



neath and on the free surface of the membrane covering the valves 
and chorda? tendinse. As the disease progresses, large or small papil- 
lary nodules, vegetations, are formed on the endocardium — endocardi- 
tis verrucosa; or ulcerations may occur as a result of destruction of 
the superficially necrosed tissue — endocarditis ulcerosa. The latter 
condition is usually found in the malignant, usually septic, form of 
endocarditis. During the course of endocarditis the pericardium and 
myocardium become involved and many organs of the body, e. cj., 
the kidneys, spleen, brain, etc., may become implicated through em- 
boli composed of masses of fibrin or necrosed tissue which become 
detached by the circulating blood, principally from the irregular val- 
vular deposits. In septic cases these emboli give rise to abscesses. 



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It is well to remember, however, that moderately severe cases of endo- 
carditis may go on to complete recovery and leave no trace of the 
original inflammation on the endocardium ; furthermore, that slight 
valvular vegetations are not infrequently found postmortem without 
any apparent clinical signs of heart disease during life. This latter 
observation can readily be explained by the fact that mild endocarditis 
is not rarely masked by the course of another disease and, unless 
presenting marked disturbance of the circulation, is very apt to be 
overlooked. More often, of course, endocarditis sets in with severe 
unmistakable symptoms. The patient vomits, suffers from chills, 
more or less high fever (102° to 105° F.), precordial distress, short 



DISEASES OF THE CIRCULATORY SYSTEM 535 

cough, dyspnea, and accelerated, sometimes irregular, pulse. These 
symptoms, however, are not sufficiently characteristic of endocarditis 
and may still leave the nature of the disease obscure until the sub- 
sequent appearance of local signs, especially of a systolic heart mur- 
mur, audible chiefly at the apex (the mitral valve being most fre- 
quently involved owing to its great vascularity) or also over the 
whole cardiac region. Sometimes endocarditis follows an apparently 
mild attack of tonsillitis with possibly a moderate joint involve- 
ment, with or without signs of chorea. As will be seen later (see 
"Endocarditis Chronica," p. 536), murmurs may subsequently develop 
at the various orifices of the heart, and, at a later stage of the disease, 
additional physical signs (hypertrophy or dilatation) may be obtained 
by percussion. 

Occasionally (in children less frequently than in adults) acute endo- 
carditis pursues a very septic and often violent course — endocarditis 
maligna {ulcerosa) . It may be preceded by pneumonia, exanthematous 
diseases, septic processes in some other parts of the body. e. g., osteo- 
myelitis, etc., or occur without any apparent cause and exhibit a symp- 
tom complex resembling either a low typhoid state or cardiac 
insufficiency with acute dilatation (cyanosis) and loud murmurs at the 
various orifices. The duration of malignant endocarditis varies. Ordina- 
rily it runs a protracted course with irregular temperature, chills, 
rigors and sweats. Sooner or later emboli develop in different organs 
of the body and the capillaries of the skin, the superadded symptoms 
varying, of course, with the organ affected. Thus, if the brain is in- 
volved, we find palsies with disorder of consciousness ; if the spleen, en- 
largement of this organ and tenderness; if the kidneys, albuminuria, 
hematuria and anasarca ; if the skin, petechia? and a pustular eruption. 
It is not rarely complicated also by purulent pericarditis. "When malig- 
nant endocarditis runs so very violent a course it, as a rule, terminates 
fatally within a few days. On the other hand, simple, benign endo- 
carditis in children is usually not dangerous to life. If free from 
complications, the symptoms begin to subside after about a week or 
ten days, eventually leading to recovery in about four weeks. In quite 
a number of cases, however, it is followed by permanent valvular dis- 
ease, with or without cardiac hypertrophy. (See "Endocarditis 
Chronica," p. 536.) Death is usually due to cardiac paralysis. 

Benign endocarditis may be mistaken for dry pericarditis, especially 
if the former is associated with articular rheumatism. The following 
table contrasts the most important distinguishing features. Both dis- 
eases, however, may coexist. 



536 DISEASES OF CHILDREN 

Simple Endocarditis Dry Pericarditis 

Blowing or musical sound. "To and fro" friction or creaking 

sound. 

Sound is associated w ; th systole or dias- Not necessarily. May be heard at any 

tole. period of cycle. 

Sound is distant. Near to the ear. 

Sound is uninfluenced by pressure with Increased. 

the stethoscope. 

Sound is conducted upward, to the ax Not so. 

ilia, and to the back. 

Sound usually loudest at apex. Anywhere over precordium. 

The diagnosis of ulcerative endocarditis is very difficult, especially 
in the incipient stage, before the appearance of a heart murmur. 
"Whenever several orifices are the seat of the murmur, paroxysms of 
cyanosis, prostration, dyspnea, and irregular temperature predomi- 
nate and cardiac dulness is increased, the diagnosis of malignant 
endocarditis is justified. The elimination of typhoid, irregular mala- 
rial fever, military tuberculosis and pyemia, the four affections with 
which malignant endocarditis is most apt to be confounded, will 
greatly facilitate the diagnosis. 

Treatment. — The treatment of endocarditis is essentially the same as 
in pericarditis — purely symptomatic. Absolute rest in bed, in the re- 
cumbent posture, and a light ice bag to the precordium. Antirheu- 
matic remedies, in conjunction with small doses of codeine and digi- 
talis to strengthen the heart. Light (meat free) easily assimilable 
diet. Cool sponging for high temperature. In malignant endocarditis 
some benefit may be derived from polyvalent antistreptococcus serum 
and transfusion. As recurrent endocarditis is not rarely due to per- 
sistent infection of the nasopharynx, it is always in order to use a 
nose and throat wash a few times daily, irrespective of the cause. 
(See "Pericarditis," p. 533.) 

Endocarditis Chronica 

(Valvular Heart Disease) 

Chronic endocarditis is most frequently a sequel of acute inflam- 
mation of the endocardium especially of the valves, and pathologically 
consists of proliferation and thickening of the valvular connective 
tissue with a great tendency to contractions and adhesions and very 
rarely to calcification. The chronic inflammatory process is usually 
limited to the left side of the heart except in cases developing during 
fetal life, when the reverse is the case. 

Coincident with the inflammatory process in the endocardium, the 



DISEASES OF THE CIRCULATORY SYSTEM 



537 



cardiac musculature undergoes gradual enlargement. This hyper- 
trophy, unless assuming exceptionally large dimensions (e.g., cor 
boviuni), is strictly speaking not a disease per se, but on the contrary, 
an effort on the part of nature to overcome or undo the evil effects of 
the disease. As the disease advances and the heart muscles lose their 




'Fig. 155. — Intense dilatation of the heart in a two-months-old infant suffering 
from congenital heart disease which was greatly aggravated by an attack of whoop- 
ing cough. 



power, get exhausted, the hypertrophy is replaced by dilatation, indi- 
cating that compensation has "ruptured," and that the disease is be- 
yond control. 



538 DISEASES OF CHILDREN 

Until failure of compensation has occurred, children may for years 
remain apparently free from any marked disturbances of health, except 
perhaps, an indistinct first sound at the apex, an unduly bounding pulse, 
throbbing of the blood vessels in the neck, rapid fatigue, palpitation of 
the heart on exertion, progressive anemia and malnutrition notwith- 
standing good appetite and digestion. Indeed, it is often for disturbance 
of the stomach that the patients are brought to the physician. Shortness 
of breath, which increases on exertion, usually forms an early manifesta- 
tion of failing compensation. It is the result of stasis in the pulmonary 
circulation with consecutive impairment of aeration. This sooner or later 
leads to passive congestion of the pulmonary alveoli giving rise to bron- 
chitis with an irritable cough, and as the heart failure increases, to 
paroxysmal attacks of dyspnea or orthopnea especially at night (''car- 
diac asthma") pulmonary edema, cyanosis, and occasionally to hemor- 
rhagic infarcts in the lung with consecutive hemoptysis. 

Simultaneously with the aforementioned manifestations pathologic 
changes go on also in other internal organs — the liver, spleen and 
kidneys. The liver and spleen are enlarged, and by pressure upon 
neighboring thoracic and abdominal organs, increase the dyspnea. 
As a sequel of the passive congestion of the liver and stasis in the 
blood vessels of the stomach and intestines, numerous gastrointestinal 
disturbances — e. g., anorexia, vomiting, constipation — develop, which 
add misery to the patient's painful existence. 

The changes in the kidneys are manifested by diminution in the 
quantity of urine, often albuminuria (slight), hyaline and cylindrical 
casts, and occasionally white and red blood corpuscles — signs of 
passive congestion. 

With increasing venous stasis there is coincident transudation of 
the fluid of the blood from the capillaries into the meshes of the 
tissues, leading to edema. At first the dropsy is limited to the ankles 
and eyelids, but as the disturbance of circulation advances it grows 
worse and involves the entire integument and the internal cavities, 
especially the abdominal and pleural cavities. Notwithstanding the 
extreme gravity of the condition, the end is not always as near as 
would be expected. The inherent power of the infantile heart is still 
capable of temporary reparation. The arrhythmia, dyspnea, and 
dropsy may disappear ; the appetite and nutrition may improve ; the 
tottering patient may again be up and around, in fact, may appear 
at his best. 

Exacerbations and improvements of the disease may recur several 
times. The improvement, as a rule, is but short lived. Very soon the 
symptoms return, and generally w T ith greater severity. Finally, after 



DISEASES OP THE CIRCULATORY SYSTEM 539 

a more or less prolonged period of illness the patient succumbs to 
heart failure. Occasionally, death occurs suddenly after severe ex- 
ertion. Quite a number of children are carried away by intercurrent 
infectious diseases, pericarditis or recurrent acute endocarditis. The 
physician should therefore always be very guarded in the prognosis. 
The relative gravity of valvular lesions is as follows: Tricuspid re- 
gurgitation; mitral regurgitation; mitral stenosis; aortic regurgitation; 
pulmonic stenosis; aortic stenosis. 

Differential Diagnosis* 

As the physical signs of valvular heart disease in children differ 
but little from those in adults, we will briefly review only the most 
essential differential points of diagnosis. 

Mitral Regurgitation. — Insufficiency of the mitral valve is char- 
acterized by a systolic blowing murmur which is loudest at the apex 
and transmitted to the axilla and near the lower angle of the left 
scapula. Accentuation of the second pulmonic sound. Hypertrophy 
of the left ventricle, and later left auricle, and sequential hypertrophy 
of the right ventricle. The pulse may be normal or accelerated, and 
with disturbed compensation — which may not occur for many years — 
irregular and unequal. 

Mitral Obstruction. — It is frequently associated with insufficiency. 
The murmur is usually presystolic or also diastolic, is best heard at 
the apex, and may be conveyed to the fourth interspace, but never 
to the angle of the scapula. The pulmonic second sound is accentu- 
ated and sometimes double. It frequently leads to hypertrophy of 
the left auricle and right ventricle. 

Aortic Regurgitation. — Aortic insufficiency is rare in children. It 
is accompanied by hypertrophy of the left ventricle, and often pulsa- 
tion of the arteries of the neck. The murmur is diastolic, loudest at 
the insertion of the right second costal cartilage and over the upper 
portion of the sternum. At first the murmur is quite noisy, but with 
ensuing disturbance of compensation it loses its intensity. It is 
usually combined with aortic stenosis, becoming the gravest form of 
valvular disease of childhood. It sometimes causes sudden death, and 
but few children survive the age of puberty. Aortic regurgitation 
may often be recognized by the peculiarly collapsing pulse, the water- 
hammer or Corrigan's pulse. 

Aortic Obstruction. — This affection is usually observed in older 
children in connection with aortic insufficiency. The murmur is 
harsh, systolic, heard loudest over the orifice, transmitted to the right, 



*See Fig. 21. 



540 DISEASES OF CHILDREN 

and sometimes over the whole length of sternum, and the arteries of 
the neck. Hypertrophy of the left ventricle. 

Tricuspid Regurgitation. — Except as a congenital defect, it most 
frequently occurs secondarily to affections of the left heart. Auscul- 
tation reveals a systolic blowing murmur, heard loudest over the lower 
part of the sternum (xiphoid) and at the juncture of the fourth costal 
cartilage. Second sound is weak. Jugular pulsation. Hypertrophy 
and dilatation of the right heart. In severe cases cyanosis, and pulsa- 
tion of the liver. 

Tricuspid Obstruction. — This condition is extremely rare as an ac- 
quired heart affection, hence calls for no detailed discussion. No par- 
ticular change in size of the heart is known. (See "Congenital Heart 
Disease," p. 528.) 

Pulmonic Regurgitation. — Insufficiency of the pulmonic valve is 
chiefly congenital, rarely acquired. The murmur is diastolic and lim- 
ited to the site of the valve — at the juncture of the left second costal 
cartilage and the sternum. Unlike that of aortic insufficiency it is not 
transmitted to the arteries of the neck. Hypertrophy of the right heart. 

Pulmonic Obstruction. — Principally a congenital malady. The 
murmur is basic, systolic, heard loudest at the left second costosternal 
junction. It is associated with hypertrophy of the right ventricle, 
and sometimes with cyanosis. (See "Congenital Heart Disease.") 

Treatment. — The management of chronic valvular heart disease in 
children is the same as in adults. It differs with the stages of the 
disease — when compensation is intact, and when it " ruptures. : 



> i 



Stage of Compensation 

The well-being and longevity of the patient stand in direct ratio 
to the capacity of the heart to compensate its insufficiency by second- 
ary hypertrophy of the musculature of one or more of its chambers. 
Hence, the aim in the treatment of chronic valvular heart disease 
should be directed chiefly to the maintenance of compensatory hyper- 
trophy. Bearing in mind the facts that with increasing circulatory 
disturbance there is on the part of the heart a spontaneous muscular 
development to overcome its difficulties so long as its supply of nour- 
ishment is sufficient and its hypertrophic process is not interfered 
with by unequal demands upon its reserve force, as is apt to occur, 
e. g., in overexertion, in intercurrent diseases and the like, we can 
readily formulate a plan of treatment which will at least for a time, 
amply meet with the aforementioned indication. Parents should be 
given to understand that the treatment of compensating heart dis- 
ease is principally prophylactic and hygienic and that its success is 



DISEASES OF THE CIRCULATORY SYSTEM 541 

commensurate with the degree of cooperation on the part of the pa- 
tient as well as those guiding his destiny, when the heart is at its 
best. Convalescence from acute or recurrent heart disease calls for 
very careful attention. Too early attempts at walking or standing 
are apt to prove disastrous, not rarely leading to sudden dilatation of 
the heart, perhaps with fatal issue. Beginning with gradual raisings 
of the patient's head and shoulders, and watching its effect upon the 
patient's heart action — its strength and rhythm — we may gradually 
allow greater liberties, provided slight exertion is unattended by 
detrimental influences. In severe cases of valvular heart disease it 
is usually not safe to permit the patient to be out and around in less 
than three months. A sojourn in a quiet inland resort is very helpful 
to recovery. 

A heart with crippled valves demands an adequate supply of healthy 
blood in the coronary arteries. This is best secured by suitable 
nutrition and a rational mode of living. The diet must be appropri- 
ate to the age of the patient, at all ages milk, cereals and vegetables 
forming the principle food ingredients; eggs, fish, light meats and 
fruit may be added off and on. Liquors and stimulants of all kinds 
should be avoided, administering instead nutrient tonics such as malt 
and cod liver oil, with or without small quantities of iron and arsenic, 
etc. 

Special attention should be paid to the action of the bowels, kidneys, 
and skin. Daily cool sponging followed by gentle massage is very in- 
vigorating. Warm clothing is essential, but unnecessary coddling of 
the patient should be interdicted. Weather permitting, the child 
should be kept outdoors from nine in the morning until five (later in the 
summer) in the afternoon, allowing him to participate in all such 
amusements as will not call for undue exertion. Racing, jumping, 
football, and baseball playing and swimming should be forbidden. 
Light athletic exercise is useful, if it gives rise to no undue fatigue, or 
disturbance of compensation (see p. 542). Passive exercise in the 
form of massage is highly to be recommended. The question of how 
much brain work a patient with poorly compensating heart disease is to 
be permitted to do, cannot be decided offhand, to apply to all cases. Its 
effect upon the general health of the patient must be watched, and 
changes in the curriculum promptly made if headache, insomnia, anemia, 
debility, excessive nervous irritability, and the like, make their appear- 
ance. 

It is of very vital importance to obviate intercurrent diseases, es- 
pecially infectious diseases, such as scarlatina, articular rheumatism, 
etc., which are apt to reinfect the endocardium and aggravate the pa- 



542 DISEASES OF CHILDREN 

tient's condition. If snch diseases prevail it is imperative, whenever 
practicable, to isolate the child, or remove him to a place where he will 
be least exposed to infection. For fear of contracting contagious dis- 
eases patients in good financial circumstances should be kept from 
visiting public or private schools and preferably be instructed at home. 

Particular attention should be paid to incipient symptoms of tonsil- 
litis, "growing pains," etc., — forerunners of rheumatism. In these 
conditions the salicylates should be resorted to early, to prevent graver 
rheumatic manifestations. Hypertrophied tonsils and decayed teeth 
should receive special care. 

With every appearance of indisposition the patient should be put to 
bed, and kept there until every vestige of the malady has abated. 

In intercurrent febrile diseases the heart demands very careful 
watching, and in the presence of any disturbance, immediate treatment. 

Formal Gymnastics — Cardiac Cases* 

These educational and hygienic exercises, as the terms are applied 
in public school systems, are examples of the type of exercise to be 
used in alternation, so as to change the groups of muscles employed 
and the vigor. The number of times and the vigor with which the 
exercise is done, will increase the effort required of the heart. The 
teacher must use her judgment with regard to the effect on individual 
cases. The children must be taught to discontinue exercising at any 
moment subjective symptoms become marked. 

Drill I — Duration 15 minutes. 

1. Hands on shoulders — Place! 

(1) Stretching left arm upward, right arm downward; hands on shoulders; 

stretching right arm upward, left arm downward — Begin! 

2. (1) Point step forward left, raising arms forward — One! 

(2) Point step sideways left, arms sideways (palms up) — Two! 

(3) Point step backward left, arms upward — Three! 

(4) Eeplacing foot, arms forward, downward — Four! 

Name of exercise — Point step forward left, arms forward; point step side- 
ways left, arms sideways; point step backward left, arms upward. 

3. Hands on hips — Place! 

(1) Deep knee bending — One! 

(2) Stretching knees — Two! 

This exercise should be taught to response commands and after it is 
thoroughly learned should be done in rhythm. Then the exercise is — 
Hands on hips — Place! 
(1) Deep knee bending — Begin! 



*The author is indebted to Dr. Robert H. Halsey for the following outline of the graduate 
exercises used in the cardiac clinics for children. 



DISEASES OF THE CIRCULATORY SYSTEM 543 

4. (1) Raising arms sideways — One! 

(2) Bending trunk sideways left — Two! 

(3) Trunk erect — Three! 

(4) Position — Four! 

Same right. Alternate. 
Name — Raising arms sideways; bending trunk sideways. 

5. Arms sideward. Trunk to right — bend. (Repeat to left.) Trunk raise. 

6. (1) Placing left foot sideways, raising arms sideways — One! 

(2) Bending trunk forward, bending left knee, touching left hand to left toe, 

right arm upward — Two! 

(3) Same as (1)— Three! 

(4) Position — Four! 

Same right. Alternate. 
Name — Placing left foot sideways, arms sideways ; bending trunk forward, 
bending left knee, touching left hand to left toe right arm upward. 

7. (1) Raising heels and arms sideways — Begin! 

8. Hands at side of shoulders — Place! 

(1) Stretching arms upward; hands at sides of shoulders; stretching arms 

sideways (palms up) — Begin! 

Drill II — Duration 10 minutes additional, making 25 minutes in all. 

1. (1) Placing left foot sideways, bending arms at shoulder level — One! 

(2) Position— Two ! 

Same right. Alternate. 

2. Hands on hips — Place! 

(1) Bending head backward (slowly) — One! 

(2) Raising head (slowly) — Two! 

Repeat. 

3. (1) Deep knee bending, raising arms sideways — Begin! 

4. (1) Placing hands behind neck — One! 

(2) Bending trunk sideways — Two! 

(3) Trunk erect — Three! 

(4) Position — Four! 

Same right. Alternate. 

5. Hands on hips — Place ! 

(1) Raising left leg forward — One! 

(2) Lowering left leg to position (slowly) — Two! 

Same right. Alternate. 

6. Hands on hips — Place! 

(1) Springing feet sideways — Begin! 

7. Hands on hips — Place! 

(1) Raising left leg sideways (slowly) — One! 

(2) Position— Two ! 

Same right. Alternate. 

8. Hands on shoulders — Place! 

(1) Raising heels, stretching arms upward — Begin! 



544 DISEASES OF CHILDREN 

Drill III — Duration 5 minutes additional, making 30 minutes in all. 

1. (1) Clapping hands over head — One! 

(2) Eaising left knee, clapping hands under left knee — Two! 

(3) Eeplacing left foot, clapping hands over head — Three! 

(4) Hands on hips — Four! 

Same right. Alternate. 

2. Hands on hips — Place! 

(1) Hopping twice on each foot, starting left — Begin! 

3. Prone fall position. Walk forward. Forward jump. Stand. 

4. Hands on hips — Place! 

(1) Raising knees upward, alternately, starting left in quick rhythm — Begin! 

5. (1) Eaising heels, arms sideways — Begin. 

Stage of Failing Compensation 

Varying with the inherent strength of the patient, the severity of 
the lesion and the precautionary measures employed, compensation 
may be maintained for a shorter or longer time — weeks, months, or 
years. However, it is only a question of time when compensation 
ruptures. As previously mentioned, the breakdown may be only 
temporary, (readily yielding to a few weeks of rest, careful feeding 
and possibly requiring also a few doses of digitalis) and recur on 
several occasions. But sooner or later the heart muscle gives way, 
the pulse becomes feeble and irregular, the breathing deep and diffi- 
cult, the urine diminished in quantity and the general health of the 
patient greatly impaired. Here rest in bed is indispensable, but this 
alone is not sufficient to restore compensation. We have to resort to 
cardiac stimulants to strengthen the heart muscle and to regulate its 
beat, and also to vasodilators, to allow the blood to flow in the arteries 
without resistance, with each ventricular contraction. Various drugs 
are being recommended for this purpose, but none meets the indica- 
tions with the same degree of certainty as digitalis, and the iodides. 
In incipient failure of compensation we usually begin, for every two 
years of the child's age, with V2 grain of the sodium iodide and % 
dram of the infusion of digitalis, or one drop of the tincture, to be 
repeated every six hours; and as the disease advances we increase the 
doses proportionately up to 1 grain of the iodide and 1 dram of the 
infusion of digitalis or 2 drops of the tincture. The cumulative action 
of the digitalis should be borne in mind and its administration discon- 
tinued if untoward symptoms arise. In this event, or where digitalis 
is not well tolerated by the stomach, we may substitute strophanthus, 
diuretin, caffeine sodium benzoate or spartein sulphate instead. The 
latter two remedies have the advantage that they may be safely given 
hyperdermically if irritability of the stomach precludes their admin- 
istration by mouth. In the early attacks of failure of compensation 
the benefits obtained from the simple mode of treatment just outlined 



DISEASES OF THE CIRCULATORY SYSTEM 545 

are often entirely beyond expectation. Sometimes within bnt a very 
few clays the urine greatly increases in quantity, the edema disap- 
pears, the dyspnea ceases, the distressing cough abates; in short, 
restoration of compensation is apparently complete. In the later 
stages of compensatory failure, however, the treatment by means of 
rest, good food, the iodides and digitalis fails to assert its magic in- 
fluence. We have to resort to symptomatic medication, especially 
with the view of relieving suffering. In this respect the treatment is 
the same as that employed in adults, morphine with or without atropine, 
by mouth or hypodermically, being the most potent remedy at our com- 
mand. 

I£ Strychninse Sulpli. gr. % 0.008 

Natrii Iodidi gr. xvj 1.000 

Inf. Digitalis fol. Hj 30.000 

Syr. Altheas- q. s. ad % ij 60.000 

M. 

S. — One teaspoonful t. i. d., for a child four 
years old. (Alterative heart tonic.) 

B; Syr. Ferri Iodidi 3 iij I 12.0 

Syr. Aurantii q. s. ad § ij [ 60.0 
M. 

S. — One teaspoonful every four hours, for a 

child four years old. (Between " heart at- 
tacks.") 

11 Liq. Ferri et Ammonii Acetatis 

Inf. Digitalis fol. aa % j 30.0 

M. 

S. — One teaspoonful every four hours, for a 
child four years old. (When dropsy is present.) 

\\ Tr. Digitalis 

Tr. Strophauthi aa 3 ij 8.0 

M. 

S. — Five to ten drops every four hours, for a 
child four years old. (In marked heart dilata- 
tion with irregularity.) 



Strychninse Sulph. gr. % 


0.012 


Caffeinse Natrii Benzoatis gr. xij 


0.800 


Aq. Destil. 3 ij 


8.000 


M. 




S. — Ten drops hypodermically, p. r. u 


, for a 


child four years old. (Quick stimulant/ 





A light diet is essential. Skimmed milk (Karell's diet for heart 
disease), 3 to 6 ounces every four hours, is often very beneficial. This 
diet may be strengthened by the addition of cereals and lactose. 



CHAPTER X 
DISEASES OF THE BLOOD AND DUCTLESS GLANDS 

DISEASES OF THE BLOOD 

Affections of the blood are of very common occurrence in children, 
especially in infancy and in those approaching puberty. At these pe- 
riods of life, owing to the rapid bodily development, the blood-form- 
ing organs are taxed to their greatest capacity, and, hence, are very 
apt to suffer on slight provocation. The anemias of children are 
usually secondary in nature, only exceptionally primary. "With the 
present inadequate state of our knowledge, however, no sharp line 
of demarcation can as yet be drawn between the various types of 
blood disease. Only too often do we find the clinical and histologic 
aspects of simple secondary anemia merging into that of splenic 
anemia, and that of the latter disease into the one of leukemia. The 
same is true of lymphatic leukemia, chloroma, and lymphosarcoma. 
For the reasons just stated, therefore, no attempt will here be made 
to offer an iron-clad classification of the diseases in question. 

In studying blood disease it is well to bear in mind that the con- 
stituents of the normal blood vary within more or less wide limits, 
and that slight ailments are prone to produce marked disproportion 
between the number of red and white blood corpuscles. 

At birth the number of red cells is about 6,000,000, and of white cells, 
between 20,000 to 30,000 per cubic millimeter. The hemoglobin is 
very high, about 110 per cent and the specific gravity 1,066. After 
the second week the red cells fall to 5,000,000, and the white cells to 
about 15,000, the hemoglobin to 100 per cent, and the specific gravity 
to 1,050. The red cells are fewer in number in the female than in the 
male. The percentage of the different leucocytes in infants presents 
the following variations: Polymorphonuclear neutrophiles, 28 to 50; 
polymorphonuclear eosinophiles, y 2 to 10; lymphocytes, 50 to 70, and 
large mononuclears, 6 to 14. The adult proportion is usually reached 
by the time the child is eight years old. Then the number of poly- 
morphonuclears rises to 65 or 75 per cent and that of the lymphocytes 
falls to 20 or 30, and of the mononuclears, to 1 to 1. Normally, coagu- 
lation of the blood usually occurs within from two to five minutes. 

546 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS 



547 



DIFFERENTIAL BLOOD COUNTS IN NORMAL CHILDREN 

(After Schloss) 



Age 




Poly- 
morpho- 
nuclears 


Lympho- 
cytes 


Large 
Mono- 
nuclears 


Eosino- 

PHILES 


Baso- 

PHILES 


months 
6-12 


| Maximum 
I Minimum 
1 Average 


35.9 
24.6 

30.4 


58.5 
50.5 
55.9 


12.2 
7.3 

9.6 


4.5 

0.0 
2.6 


0.8 
0.1 
0.4 


1-2 yrs. 


( Maximum 
I Minimum 
[ Average 


39.7 
27.5 
36.3 


58.8 
45.3 
51.2 


11.7 
6.7 
8.5 


5.0 
1.6 
3.2 


0.5 
0.0 
0.2 


2-3 yrs. 
3-4 yrs. 


f Maximum 
{ Minimum 
[ Average 

f Maximum 
< Minimum 
[ Average 


44.3 
33.2 

38.7 

54.1 
36.2 
44.7 


55.0 
43.5 
49.9 

47.6 
32.2 
39.1 


11.3 
5.0 

8.2 

16.2 
6.0 
11.2 


0.5 
3.1 

6.0 
4.2 
1.5 
2.8 


1.2 

0.0 
0.4 

0.9 
0.0 
0.5 


4-5 yrs 


f Maximum 
i Minimum 
{ Average 


51.7 
42.2 
48.5 


49.5 
38.4 
42.1 


6.7 
3.4 
6.0 


4.0 
1.6 

2.6 


0.6 
0.3 
0.3 


5-6 yrs. 


f Maximum 
-< Minimum 
[ Average 


61.8 
52.6 
56.5 


36.7 
21.2 
29^9 


16.0 

6.5 

10.0 


4.7 
0.7 
2.5 


1.0 

0.3 
0.6 


6-7 yrs. 


f Maximum 
< Minimum 
(_ Average 


61.3 
52.3 
56.0 


34.1 
24.5 
30.4 


15.7 
8.1 

10.8 


4.7 
0.1 
2.2 


0.6 
0.0 
0.2 


7-8 yrs. 


f Maximum 
•< Minimum 
[ Average 


72.0 
45.2 
54.4 


39.1 
21.1 
32.5 


15.2 

6.7 

11.6 


3.5 
0.0 
6.1 


0.2 
0.0 
0.6 



Anemia Simplex, Chlorosis 

(Green Sickness) 

Both, of these conditions present identical pathologic changes in the 
blood — reduction in the number of red cells, decrease of hemoglobin, 
without marked changes in the cells themselves — but differ some- 
what in the etiology and course. Thus, while chlorosis is ordinarily 
encountered in girls at puberty, and almost invariably ends in re- 
covery without any grave alterations in the general health, anemia 
is a disease of younger children, and if occurring in infants very fre- 
quently forms the forerunner of that type of blood disease which is 
generally described as pseudoleukemia infantum (q. v.). Anemia in 
the newborn may be congenital (disease of the mother, especially 
syphilis, tuberculosis, and malaria) or acquired (hemorrhage; sepsis). 

Anemia as well as chlorosis is manifested by pallor of the face 
(waxy or green complexion) and mucous membranes, headache, dys- 



548 DISEASES OF CHILDREN 

peptic symptoms, undue fatigue after slight exertion, attacks of pal- 
pitation of the heart and of dyspnea, general debility and excessive 
irritability of the nerve system. In. young infants the ears usually 
show a peculiar waxy transparency. Auscultation often reveals hemic 
murmurs along the large veins of the neck and at the base of the 
heart, which differ from organic murmurs by their inconstancy and 
frequent change in their intensity and location. 

In addition to the aforementioned manifestations, chlorosis in ma- 
ture girls is very prone to give rise to amenorrhea, dysmenorrhea, and 
less frequently to monorrhagia with consequent aggravation of the 
original condition; severe chlorosis is apt to be complicated by venous 
thrombosis, especially in the lower extremities and the brain sinuses, 
and occasionally by secondary gangrene and embolism. Of course 
such occurrences are very exceptional. The very great majority of 
cases of chlorosis, as already stated, improve rapidly and fully, al- 
though relapses are not uncommon. 

The management of anemia and chlorosis to a great extent varies 
with the numerous etiologic factors. The general health should be 
improved by suitable nutritious diet, plenty of outdoor air, in older chil- 
dren cold shower baths with gentle massage, ample sleep, and avoidance 
of undue excitement and physical and mental overexertion. Dyspepsia, 
habitual constipation, diarrhea, loss of blood (epistaxis, etc.), hered- 
itary syphilis, malaria, tuberculosis, heart and kidney affections, and 
all other diseases as are apt to undermine the system should receive 
prompt and continuous attention. Where circulatory disturbances 
are very pronounced, rest in bed is indispensable. Medicinally, iron 
and arsenic are the remedies of choice. The following combination 
acts splendidly : 



Liquoris Arsenici Chloridi 3 i 


4.00 


Tr. Ferri Chloridi 3 iii 


12.00 


Syr. Aurantii q. s. ad % iii 


90.00 


M. 




S. — One teaspoonful every three hours 


, for a 


child six vears old. 





In older children to avoid destruction of the teeth, the iron and 
arsenic, without syrup, may be prescribed with instructions to be 
taken in capsule form, each dose being prepared before taking it in 
accordance with the directions given on page 104. 

Digestives and tonics (cod liver oil) will be found to act as useful 
adjuvants. Change of air, preferably to mountainous regions. 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS 



549 



Pseudoleukemia Infantum, Splenica 
(von Jaksch's or Splenic Anemia) 

This condition was first described by von Jakscli in 1889 as a 
clinical entity. It is observed in infants from six to twenty-four 
months of age, corresponding with the age when rachitis and gastro- 
intestinal affections are most prevalent. Hence the reason why some 
authors look upon it as a secondary rather than a primary anemia. 

The chief alterations in the blood are reduction of red cells and 
hemoglobin (sometimes as low as 20 per cent), the presence of many 




Fig. 156. — Splenomegaly in association with von Jakscli anemia. 



nucleated red corpuscles, and a considerable increase in the number 
of leucocytes, mostly of the mononuclear type. This blood picture 
essentially corresponds to that of ordinary secondary anemia, In 
pseudoleukemia infantum, however, there is an enormous enlarge- 
ment of the spleen and usually also slight enlargement of the liver 
and lymphatic glands. 



550 DISEASES OF CHILDREN 

The general symptoms differ but little from those observed in 
severe anemia. The same applies to the treatment. The syrup of the 
iodide of iron with the syrup of the hypophosphites and red bone mar- 
row seem to exert a specific action in the majority of cases. 

Pseudoleukemia Lymphatica 

(Hodgkin's Disease, Adenie, Lymphadenoma) 

In contrast to splenic anemia this disease is not peculiar to infancy 
and is characterized by multiple hyperplasia of the lymph glands with 
progressive anemia. The cervical glands are most commonly and 
severely attacked, but the lymphoid tissue of the entire body is more 
or less involved. It closely resembles tuberculous adenitis, except 
that it is much more uncommon than tuberculosis and that in the 
latter condition the glands show a greater tendency to caseation and 
suppuration. In doubtful cases the tuberculin test may prove de- 
cisive in the diagnosis. 

The changes in the blood and the clinical manifestations are identi- 
cal with those observed in severe anemia. Occasionally, there are local 
pressure symptoms, such as pain, edema, cough and dyspnea. 

Under suitable treatment (see "Anemia," p. 548) recovery or at 
least arrest of the disease is possible. Of late arsenic in the form of 
salvarsan has been employed with considerable success. X-ray therapy 
also is worth trying and some clinicians advise surgical intervention. 
Intractable cases often terminate in leukemia. 

Leukemia 

( LEUCOC YTHEMIA ) 

As the term indicates, leukemia is characterized principally by an 
abnormal increase in the number of leucocytes (sometimes reaching 
as high as a million), and by the presence of unusual types of these 
cells, i. e., "Markzellen" (myelocytes), "Mastzellen" (nutritive cells), 
and giant basophiles. From a pathologic point of view it is custom- 
ary to distinguish two forms of leukemia: (1) Lymphatic leukemia, 
in which the lymphatic glands are chiefly involved (hyperplasia) ; 
and (2) splenomedullary or myelogenic form, in which the spleen 
(greatly increased in size) and the bone marrow (hyperplasia) are 
the principal seats of the lesion. Mixed forms also are encountered. 
The principal difference between the two forms of leukemia are the 
preponderance of lymphocytes in lymphatic, and myelocytes in splenic 
leukemia. The red cells and hemoglobin are reduced in both varieties. 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS 551 

The clinical manifestations are essentially identical with those of 
pernicious anemia (g. v.), pins enlargement of the lymphatic glands, 
(of the neck, axilla and inguinal regions), the spleen and liver. There 
is a marked tendency to hemorrhage in the skin and mucous mem- 
branes; progressive anemia; recurrent fever; edema. The disease may 
run a very acute course (acute leukemia), and end fatally within a 
week or two, or proceed a slower course (chronic leukemia), and 
lead to a fatal issue after a few months. 

As the nature of leukemia is entirely obscure, little else can be 
done but treat it symptomatically. (See Anemia and Pseudoleukemia.) 

Pernicious Anemia 

This form of anemia is characterized by great diminution in the 
number of red cells (2,000,000 to 1,000,000 per c. mm.) ; reduction in 
the total quantity of hemoglobin with a comparative increase of the 
hemoglobin in the red cells; increase in the size of the red cells with 
predominance of megaloblasts ; loss of cohesive quality of the red 
cells (their failure to form rouleaux), and, finally, absence of distinct 
changes (or slight reduction) in the number of the leucocytes. 

This blood affection is very rarely met with in children. As in 
adults, it may occur secondarily to protracted simple anemia or in 
consequence of abstraction of blood by intestinal parasites, e. g., 
bothriocephalus latus; uncinaria (q. v.). 

In the beginning the symptoms resemble those of severe simple anemia 
(q. v.), but at a later stage of the disease the condition is greatly ag- 
gravated by supervening hemorrhages from the mucous membranes, 
cutaneous ecchymoses, and general dropsy. In such cases death in- 
variably occurs within a few months. 

Pernicious anemia occasionally gives rise to lesions in the spinal 
cord with corresponding symptoms (paralysis of the extremities, etc.). 

Postmortem examination usually reveals fatty degeneration of the 
internal organs. 

The Treatment. — The treatment is the same as in severe anemia. 
(See p. 518.) In addition, removal of the intestinal parasites, if 
present, and transfusion. 

A. D. Espine (Kev. Med. de la Suise Eomande, August, 1918) re- 
ports the recovery of two young infants treated by a special serum. 
The serum was obtained by venesection of animals at the height of 
the regeneration of blood following a previous extensive withdrawal 
of blood. This "hematopoietic serum" was injected subcutaneously 
daily in closes of from 5 c.c. to 10 c.c. The improvement was gradual. 



552 



DISEASES OF CHILDREN 



Hemorrhea Congenita 

(Hemophilia) 

Hemophilia is an inherited, congenital tendency to posttraumatic 
or spontaneous, profuse, often uncontrollable, hemorrhage. It affects 
the male much more frequently than the female, though the disease 
is transmitted through the female. The disease becomes less marked 
with advancing age. 

According to Haliburton, the process of blood coagulation is as 
follows: 



Blood platelets and leuco- 
cytes give thrombogen 



The blood cells and tissues of 
the body give thrombokinase 



Blood plasma furnishes 
n protein fibrinogen 



In the presence of calcium 
salts thrombokinase activates 
thrombose!! into an enzyme 



Thrombin acts on fibrinogen to give 
Fibrin 

Minot and Lee maintain that the active coagulating principle of 
the tissue juice is derived in part, if not wholly, from the blood 
platelets and that in hemophilia there is an hereditary defect in the 
platelets, though normal in number. In addition to this there is also 
a congenital permeability and friability of the blood vessels. 

"While, as previously alluded to, the hemorrhage may start spon- 
taneously, in the great majority of cases it follows some trivial injury. 
A scratch or the prick of a pin or slight abrasion of the body surface, 
vaccination, snipping of the frenum linguae, circumcision, extraction of a 
tooth, opening of abscesses, etc., are followed by severe, often by un- 
controllable, hemorrhage. Any undue exertion of a muscle or a group 
of muscles (e. g., jumping off a chair, sudden twisting of an arm), a 
bump or a blow, etc., often gives rise to a profuse extravasation of 
blood into the skin or joints. Forcible blowing of the nose may be 
followed by an exsanguinating nosebleed, and in a case under obser- 
vation sneezing produced an enormous hemorrhage from the nose and 
ear (rupture of the drum!) which nearly ended fatally. In girls 
hemorrhages may occur from the vagina (often mistaken for men- 
struatio precox) long before the age of puberty; and with establish- 
ment of menstrual function, the bleeding may be so profuse as to 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS 553 

leave the patient monthly in a state of collapse. Hematemesis, hemor- 
rhage from the bowels and hematuria are less common, and bleeding 
into the serous cavities (peritoneal, pleural and pericardial) and the 
brain are still less frequent. Hemophilia in the newborn may be 
manifested during or immediately after birth by severe hemorrhages 
occurring from abrasions and contusions sustained during delivery, 
or after cutting the umbilical cord. These hemorrhages are not to 
be mistaken for hemorrhage in the newborn complicating sepsis (see 
p. 229), or the so-called transitory hemophilia which is manifested by 
idiopathic umbilical hemorrhage (see p. 222), or fearful, sometimes 
fatal bleeding following ritual circumcision. In this form of hemo- 
philia the tendency to hemorrhage is greatest between the seventh 
and fourteenth clays of life, gradually lessening in intensity until the 
infant reaches the age of two or three months, when it disappears en- 
tirely. The differential points of diagnosis between hemorrhea con- 
genita and hemorrhea acquisita will be spoken of in the discussion of 
the latter affection. 

Treatment. — Little of a permanent cure can be expected from treat- 
ment, except in mild forms of hemophilia ("partial bleeders"). In 
these cases gelatine as a food, and calcium chloride, in from 2 grain 
to 5 grain doses, twice daily, to be continued for months or years, 
will prove of some benefit. Thyroid gland substance, in small doses, 
continued for weeks at a time, is deserving of trial. For the immedi- 
ate arrest of the hemorrhage we must resort to transfusion or injec- 
tion of whole blood (2 or 3 ounces two or three times a day) into the 
gluteal region. In slight local hemorrhage good results are often ob- 
tained from the topical application of thrombokinase and thrombo- 
plastin. 

"We should guard against injuries and operative interference (gela- 
tin feeding before operation is helpful) of all kinds. 

Bleeders, especially females, should not marry. 

Hemorrhea Acquisita 

(Purpura Simplex, Purpura Hemorrhagica s. Morbus 
Maculosus, Purpura Fulminans) 

Purpura is an acquired affection of the blood or its vessels char- 
acterized by hemorrhage into the skin, mucous membranes and other 
tissues, and by more or less marked constitutional disturbance. 

The etiology of the disease is still obscure, but is probably a toxemia 
or a specific microorganism which invades the blood and is essentially 
identical with septic hemorrhage seen in the newborn (q. v.). 



554 DISEASES OF CHILDREN 

Purpura is most frequently observed in children (male and female) 
over five years of age, and more rarely in younger ones. It occurs 
either as a primary affection, or in connection with acute infectious 
diseases, such as scarlatina, measles, typhoid, influenza, etc., and 
shows a predilection for poorly nourished, anemic and rachitic chil- 
dren living in dark, damp dwellings, with bad hygienic surroundings. 

Consonant with the degree of severity of the affection, it is cus- 
tomary to distinguish the following forms of purpura: 

1. Purpura Simplex. — The hemorrhage is confined to the skin only, 
and appears as pinhead- to lentil-sized spots at first upon the lower 
extremities, but later also on the other portions of the body. Aside 
from occasional prodromata consisting of gastroenteric disturbance 
of brief duration, it is free from constitutional manifestations. The 
majority of these cases pursue a favorable course. The petechias 
either subside entirely within from one week to one month, or return 
at short or long intervals, in which latter event transition into a 
severe type of the disease is not uncommon. 

2. Purpura s. Peliosis Rheumatica. — (See p. 422.) 

3. Purpura Hemorrhagica (Morbus Maculosus Werlhofii). — This 
form of purpura is manifested by hemorrhages in the skin as well as 
in the mucous membranes. Its onset is either sudden or preceded by 
slight prodroniata or purpura simplex. The skin petechias may vary 
in size from a lentil to the palm of a hand, and do not disappear on 
pressure. They usually spread rapidly over the entire body.^ The 
hemorrhages into the mucous membranes are rarely very profuse. 
As a rule, there are only ecchymoses upon the mucous membranes of 
the nose, gums, and pharynx, but in severe cases the hemorrhagic 
tendency may extend to almost every structure and organ of the body, 
so that the patient bleeds from the nose, mouth, ears, retina and 
choroid, throat, lungs, stomach, bowels, kidneys, genitalia, etc., and 
sometimes even into the brain and cord. Under these conditions there 
are well-marked constitutional symptoms (prostration, headache and 
articular pain, cerebral symptoms as a result of the anemia or menin- 
geal hemorrhage, colic and tenesmus, etc), but in mild cases the pa- 
tient may appear perfectly well. The course of the disease, therefore, 
varies with the seat and amount of the bleeding. An attack of pur- 
pura hemorrhagica of medium severity usually lasts from ten to 
fourteen days. After about a week the cutaneous ecchymoses begin to 
change from the original red to bluish, yellow, greenish and brown, 
and disappear entirely within another week. The hemorrhages from 
the mucous membranes and viscera also gradually cease, the general 
condition of the patient improves, and recovery ensues, apparently 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS 555 

without any serious consequences. On the other hand, in a great 
many cases, the course of the first attack may be protracted for weeks 
and months by frequent recurrence of the bleeding, and lead to pro- 
found anemia and death, or establish a tendency to relapses, which 
may manifest themselves on slight provocation. 

The blood changes vary with the degree of the hemorrhage. We 
usually find the usual manifestations of profound anemia. 

4. Purpura Fulminans (Henoch). — This type of purpura is essen- 
tially identical with the former variety, except that its course is ex- 
tremely rapid and violent, with severe constitutional symptoms, such 
as chills, vomiting, intense abdominal pain and intestinal hemorrhage, 
hyperpyrexia, cerebral symptoms, and collapse. It is invariably fatal, 
death taking place with symptoms of cardiac paralysis, within from 
one to four days. Postmortem findings resemble those of severe anemia. 

Purpura may occasionally be complicated by gangrene of the skin, 
subcutaneous tissue or mucous membranes, rendering the prognosis 
very much worse. 

In the early stage of the disease heniorrhea acquista may be mis- 
taken for hemorrhea congenita, infantile scurvy, and exanthemata 
(scarlatina, morbilli diphtheria, variola, typhoid, etc.) with hemor- 
rhagic symptoms. 

Differential Diagnosis 

Hemorrhea congenita presents a history of an hereditary tend- 
ency, most frequently follows some local injury, and if it occurs 
spontaneously, it very rarely involves several portions of the body 
simultaneously. 

Infantile scurvy is an affection principally of early infancy and as- 
sociated with malnutrition. The hemorrhage is also deepseated (sub- 
periosteal). 

Exanthemata have pathognomonic symptoms of their own (high fever) 
which are wanting in purpura. The concurrence of the former with the 
latter, however, should not be lost sight of. 

Septic purpura can readily be recognized by the other septic symptoms. 

Treatment. — The treatment of purpura is very unsatisfactory. 
Mild cases usually recover spontaneously, and grave ones may go from 
bad to worse even under the best mode of treatment. In bad cases 
transfusion is indicated. Absolute rest in bed, nutritious diet, plenty 
of fresh air, iron and arsenic, and the administration of fresh fruit 
juice will enhance the arrest of milder forms of the disease. 

Local hemorrhage should be treated in accordance with the rules 
laid down for the management of bleeding from other causes (com- 



556 DISEASES OF CHILDREN 

pression, ice bags, styptics, etc). After cessation of the bleeding 
tonics are useful. Stimulants, in collapse. 

Morbus Addisonii 

(Bronzed Skin) 

The pathogenesis of this affection is as vet awaiting correct inter- 
pretation. While in the majority of cases postmortem examination 
reveals disease of the suprarenale (caseation or calcification), cases of 
Addison's disease are also on record which failed to show distinct 
pathologic change in these glands. The disease usually attacks chil- 
dren over ten years of age, and, exceptionally, younger ones. It is 
manifested by progressive emaciation, dyspepsia, uncontrollable diar- 
rhea, anemia, and bronze-like discoloration of the skin and mucous 
membranes. The discoloration begins at the breast nipples, axillary 
regions, hands and face, and gradually affects the entire body (ex- 
cept the conjunctivae and nails). The patients succumb within a few 
months or years to exhaustion and paralysis of the heart. 

Hematinics, roborants, and the thymus, suprarenal, parathyroid 
and pituitary extracts, are deserving of trial. 

Diseases of the Spleen 

Spleen affections are manifested principally by enlargement t)f the 
organ, demonstrable by palpation and percussion. 

Movable Spleen 

(Wandering Spleen, Lien Mobilis) 

This condition is important chiefly from a diagnostic point of view, 
as it is apt to be mistaken for splenic enlargement. It differs from 
the latter by the absence of constitutional symptoms and by the softer 
consistence of the spleen. It is usually associated with general atony 
of the entire musculature, especially of the abdominal wall, and in 
older children not rarely with enteroptosis, floating liver and kidneys. 
Subjective symptoms may be absent. Older children may complain 
of a feeling of weight or pain in the left side, colic, and nausea. 

Mild cases frequently obtain permanent relief from the use of an 
abdominal binder and general tonic treatment (massage, cod liver 
oil, arsenic). In very pronounced cases surgical interference is in- 
dicated. 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS 557 

Acute Splenitis 

(Splenic Congestion) 

An acute splenic enlargement may be caused by malaria, typhoid, 
recurrent fever and miliary tuberculosis, more rarely by influenza, 
rotheln, scarlet fever, tuberculous meningitis, mumps, erysipelas and 
angina. Very rapid and intense enlargement of the spleen may occa- 
sionally be followed by rupture of the spleen, hemorrhage in the ab- 
dominal cavity and death. 

In the majority of instances the splenitis subsides spontaneously 
with the underlying cause. If the disease is due to direct infection 
by pyogenic microorganisms, trauma (with open wound) or metasta- 
sis, it may end in suppuration (splenic abscess). Occasionally the 
inflammation extends to the surrounding tissues, especially to the 
capsule of the organ, perisplenitis, and gives rise to inflammatory ad- 
hesions to neighboring structures (diaphragm, colon, or fundus ven- 
triculi). 

Chronic Inflammation of the Spleen 

(Chronic Hypertrophy, Splenomegaly) 

Occasionally chronic enlargement of the spleen is the result of 
acute splenitis. Most frequently, however, it develops insidiously in 
connection with chronic malaria, syphilis, tuberculosis, rachitis, leu- 
kemia, pseudoleukemia and amyloid degeneration. 

The symptoms vary with the original cause and the degree of pres- 
sure exerted by the spleen upon the neighboring structures. No at- 
tempt will therefore be made to go into a detailed description of the 
symptomatology. Mention may here be made of the fact that in the 
so-called "idiopathic" splenomegaly the patient may appear entirely 
free from constitutional manifestation. 

Treatment. — This is symptomatic. If the spleen alone is involved 
and gives rise to grave pressure symptoms, splenectomy may have to 
be resorted to. 

Banti's Disease 

This disease is infrequently observed in children. In some cases a 
history of syphilis is obtainable. It is characterized by spleno- 
megaly, anemia, ascites, cirrhosis of the liver, and hemorrhages. 
Postmortem examination usually discloses a fibrosis of the retic- 
ulum of the spleen, liver and the portal vein. The bone marrow 
and lymph nodes are normal. Early splenectomy is said to cure the 
affection. The diagnosis can be made only by exclusion of similar 
spleen and liver diseases. 



558 



DISEASES OF CHILDREN 



Primary Family Splenomegaly (Gaucher) 

This peculiar, apparently congenital, enlargement of the spleen is 
occasionally (only 4 cases came under my personal observation) en- 
countered in two or more members of the same family. Although ac- 
curately described by P. C. E. Gaucher in 1882 (De 1' epithelioma 
primitif, etc., etc.) and carefully studied since then in the living and 





Fig. 157. Fig. 158. 

Figs. 157 and 158. — Primary family splenohepatomegaly, Gaucher type, in brother 

and sister. 



postmortem, its etiology is still shrouded in mystery. It is generally 
overlooked in early infancy, or the splenic and hepatic enlargement 
is attributed to rachitis, splenic anemia or syphilis. As the child 
grows older, it is found that notwithstanding good hygienic care and 
treatment, the affected organs assume greater dimensions, often oc- 
cupying the entire abdominal cavity. (Fig. 157.) In addition to this 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS 



559 



symptom the patient usually suffers from anemia, and its accompany- 
ing manifestations; occasional hemorrhage from the nose and mouth; 
pigmentation of the skin, and enlargement of the lymph nodes. The 
disease usually proceeds a chronic course and is sometimes marked 
by remissions or even spontaneous arrest of further enlargement. In 
the majority of instances, however, death supervenes within from 
two to ten years as a result of passive congestion of the different ad- 
jacent organs which are displaced and pressed upon by the ever- 
growing spleen and liver. 

A correct diagnosis can most frequently be made by excluding 
syphilis (Wassermann reaction positive), tuberculosis (tuberculin test 
positive), splenic anemia (definite blood changes, liver usually free), 
and Banti's disease (spleen but moderately enlarged, usually ascites, 
not congenital, nor a family affection). 

Early splenectomy is the only procedure that offers any prospect of 
recovery. Cases in which the splenic enlargement progresses very 
slowly are best let alone. 

Postmortem examination usually discloses an endothelial hyper- 
plasia in the spleen, liver, lymph nodes and bone marrow. To give a 
definite idea of the enormity of the splenic enlargement in this affec- 
tion I may add that in a case of a thirteen-year-old girl reported by 
Bovaird (Am. Jour. Med. Sc, 1900), the spleen weighed 12% pounds. 

Adenitis and Lymphadenitis 

Acute and chronic involvement of the lymph glands are of quite 
common occurrence in children. We may classify them in accord 
with their etiology as follows : # 

'(a) Trauma and skin diseases 
(6) Nasopharyngeal disease 
(<?) Dental caries and stomatitis 
(d) Acute infectious diseases, 
more particularly glandu- 
lar fever, German measles 
(a) Hyperplasia following acute 

lymphadenitis 
(6) Syphilis 

(c) Tuberculosis (scrofulosis) 

(d) Leukemia and pseudoleuke- 
mia 



rnflammations 



Acute lymphadenitis due to 
local infections 



Chronic lymphadenitis 



Tumors 



Lymphosarcoma 
Malignant lymphoma 
Chloroma 

Secondary malignant tumors 



( Carcinoma 
{ Sarcoma- 



^Diagram modified after A. Caille. 



560 



DISEASES OF CHILDREN 



The glands most frequently affected are the cervical, submaxillary, 
submental, axillary, peribronchial, mesenteric and inguinal. Ordi- 
narily with removal of the cause, the glandular enlargement gradually 
disappears; in a number of cases, however, they remain permanently 
indurated. 

1. Diseases cf the ear (auditory meatus), eruptions above the face, and occa- 
sionally during parotiditis. 

2. Mastoiditis and infectious, and eruptions affecting the scalp. 

3. Infections of the chin, tongue and lower lip. 

4. Infections of the mouth and teeth, stomatitis, rubeola and rubella. 

5. Infections of the tonsils, in the mild attacks of scarlet fever and at first in 
variola. In severe scarlet fever 5, 6, 7 and 8 may be much affected. 




Fig. 159. 



Fig. 160. 



-Distribution of the principal lymphatic glands of the neck 
and trunk. 



6. Pharyngeal infections and inflammation, therefore in retropharyngeal lymph- 
adenitis. Also in severe scarlet fever and rubella. 

7. Infections of the scalp and scarlet fever. 

8. During the course of diphtheria, 4, 5, 6, 7 and 8 may become prominently 
enlarged, so that the whole neck appears badly swollen and tender. 

9. Infections of the neck and occasionally during the course of diphtheria. 

10. Infections affecting the arm, the axilla and the upper portions of the chest 
anteriorly and posteriorly. 

11. Infections of the hand, and especially of the three inner ringers; quite fre- 
quently this is enlarged during the course of a syphilitic eruption. 

12. Infections affecting the lower limbs, particularly the thigh and sometimes dur- 
ing the course of syphilis. In rare instances these glands are affected in rubella. 

Treatments — Attention to primary cause ; ice bag to the swelling or 
an ointment of plumbum iodide or ichthyol. If the swelling persists, 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS 561 

hot compresses to hasten suppuration, incision and drainage. Tuber- 
culous glands are nowadays let alone until they show signs of break- 
ing- down. They are then incised and drained. In some of these cases 
tuberculin treatment (q. v.) seems to do good. Glands that give rise 
to persistent constitutional symptoms should be removed. Syrup of 
iodide of iron and cod liver oil often act very beneficially. 

DISEASES OF THE THYROID GLAND 

The normal thyroid gland is somewhat larger in children, especially 
girls, than in adults. It consists of three lobes, one middle small 
lobe (inconstant) and two larger lateral lobes. The latter are con- 
nected by an isthmus. The lateral lobes are situated on each side of 
the trachea along the second and third tracheal rings; the middle lobe 
lies in front of the thyroid cartilage and ascends upward in the direc- 
tion of the middle of the hyoicl bone. As the gland is thin and often 
lies deeply imbedded in the neck, it is very rarely possible by palpa- 
tion to determine the size of a normal thyroid. 

Thyroiditis 

(Strumitis) 

Primary inflammation of the thyroid gland is usually of traumatic 
origin (direct violence, or injury during delivery). It is of very rare 
occurrence. More frequently we meet with secondary thyroiditis, as 
a rule, in connection with acute exanthematous diseases and occasion- 
ally with parotitis, malaria, and articular rheumatism. 

The symptomatology consists of swelling of the gland, pain on 
pressure as Avell as on moving the neck, and in some cases redness, 
fluctuation and suppuration, and more or less marked pressure symp- 
toms. 

The inflammation usually disappears under local application of 
cold. Should an abscess form, it demands immediate evacuation of 
the pus and drainage. 

Severe protracted thyroiditis not rarely leads to atrophy of the 
gland. 

Goiter 

(Struma) 

As in adults, the thyroid gland of children is subject to hyperplasia 
and cystic degeneration. In countries ivhere goiter is endemic it is 
not rarely observed in very young infants, and is probably of ante- 



562 DISEASES OF CHILDREN 

natal origin. On the other hand, sporadic goiter, as a rule, develops 
at the period of puberty, particularly in girls. 

Small goiters may remain free from any manifestations, except the 
local swelling in the anterior portion of the neck, while goiters large 
enough to exert pressure upon the adjacent structures may prove a 
menace to life by compression of the trachea, and the large blood 
vessels and nerves which abound in the neck. The pressure symp- 
toms ordinarily consist of headache, dizziness, aphonia, dyspnea and 
paroxysmal cough. This grave symptom complex, however, is of 
unusual occurrence. 

On the whole, the prognosis is favorable. The great majority of 
cases of goiter yield promptly to internal administration of small 




Fig. 161. — Goiter in girl eleven years old. 

doses of iodine, with or without thyroid or parathyroid gland sub- 
stance, and external use of iodine ointment. Large goiters, causing 
marked pressure symptoms, call for their extirpation. 

In countries where goiter is endemic its development to a great ex- 
tent may be prevented by change of residence, by boiling the drink- 
ing water, and by drinking large quantities of distilled water. 

In infants goiter may be mistaken for a large hygroma cysticum 
colli congenitum or other cysts of the neck, and in older children for 
exophthalmic goiter. Cysts of the neck are characterized by marked 
fluctuation and rapid development, and usually start from the sub- 
maxillary region. 



DISEASES OP THE BLOOD AND DUCTLESS GLANDS 



563 



Exophthalmic Goiter (Basedow's or Graves's Disease) 
It is characterized, in addition to the goiter, by tachycardia, muscular 
tremor, exophthalmos, Graefe's symptom, general ill health, vasomotor 
disturbances (flushes of the skin alternating with pallor), and pig- 
mentation of the skin. Rapid growth in height is not an uncommon 
manifestation. 

Treatment. — Absolute rest to body and mind. Small doses of atro- 
pine to subdue excessive activity of the thyroid. Bromide and dig- 
italis for tachycardia and tremor. Attention to tonsils, teeth and other 
sources of irritation. 

Cretinism 
(Endemic or Goitrous Cretinism, Sporadic Cretinism 
and myxidiocy) 
Cretinism is due to partial or total arrest of the secretion of the 
thyroid gland, in consequence of congenital or acquired (extirpation) 
absence, atrophy (from strumitis, syphilis, tuberculosis, or neo- 
plasms), or goitrous degeneration of the gland. 




Fig. 162. — Hypothyroidism — Myxidioey, in a girl sixteen years old. 



564 



DISEASES OF CHILDREN 



Endemic cretinism occurs in children living in countries where 
goiter is endemic, or in descendants of people coming from these re- 
gions, and is very frequently associated with goiter. On the other 
hand, sporadic cretinism is observed in children coming from other 
parts of the world. The term "myxidiocy" is usually reserved for 
the pronounced forms of cretinism which are associated with marked 
pseudolipomatosis. (For full description of " Cretinism, ' ' see p. 721.) 

DISEASES OF THE THYMUS GLAND 

The thymus gland consists of two lateral lobes coming in close 
contact along the middle line. It is situated in the anterior portion 




Fig. 163. — Large thymus. 

of the neck and superior mediastinum, extending from the lower 
border of the thyroid gland to the upper border of the fourth rib. 
The thymus varies greatly in size and weight. It is about 2% 
inches in length, iy 2 inches in width (at its lower portion), and 
!/4 of an inch in thickness. It attains its greatest development 
(weighing % ounce) between the first and second years, and 
undergoes rapid degeneration soon after puberty, so that, at the 
age of twenty, it is a mere vestige of lymphoid tissue and fat. In 
children under six years of age, light percussion over the supe- 
rior mediastinum reveals a triangular field of duiness, its base be- 
ing on a line with the sternoclavicular articulations, and its apex 



DISEASES OP THE BLOOD AND DUCTLESS GLANDS 565 

the second rib. It is well to remember, however, that similar dulness 
is obtained in enlarged bronchial glands. 

We have yet a great deal to learn about the status of the thymus 
gland in the human economy. Though fully dispensable in adult life, 
it is essential to the growth and development of the child. The func- 
tion of the thymus is more or less dependent upon and in part regu- 
lated by that of the thyroid, and vice versa. Thus, there is less need 
of thymus when the thyroid is gone, and similarly less thyroid suffices 
when the thymus is removed. Moreover in cases of hypertrophy of 
the thymus, where the elaboration of its secretion is excessive, re- 
moval of the thyroid is usually followed by sudden death, which 
shows plainly that in the absence of the regulating power of the 
thyroid an excess of thymus secretion is destructive to the human 
economy. Experiments on dogs by H. Klose* have shown that about 
two weeks after total removal of the thymus gland a " stadium adi- 
positas" of from two to three months' duration develops, followed 
by loss in weight, general bodily weakness, frailty of the bones, ar- 
rest of growth in spite of ravenous appetite, and frequently sponta- 
neous fractures. This cachectic state, or cachexia tlnj)nopriva is ac- 
companied by idiotia thymopriva with a terminal coma thymicum. 
Postmortem examination discloses signs of rachitis, osteomalacia and 
osteoporosis, the lime salts content being reduced to about half its 
normal percentage, although the ratio of the lime salts was unaltered. 
According to the same author the deficiency in undissolved lime salts 
is dependent upon an increased acid action owing to the failure of 
the thymus to inhibit the formation of acids in the organism or to 
neutralize or mask an excess thereof. This "hypothetic" nucleinic 
acid intoxication, he believes, produces in growing bone defective 
construction, rachitis with abnormal softness and flexibility, while in 
fully formed bone increased destruction, osteomalacia, and osteo- 
porosis with abnormal fragility. 

With these laboratory observations in view we are enabled to ob- 
tain a clearer conception of the manifestations accruing from the 
effects of thymus disease or congenital abnormality, be it hyperplasia 
or hypoplasia of the thymus. 

Like other glands of the body the thymus gland is subject to acute 
and chronic intlammatioii (thymitis) with consecutive hyper plasia, 
or premature atrophy ; tuberculosis ; syphilis, and neoplasms. 



""Brooks and Langerhans' "Text-Book of Pathology." 



566 DISEASES OF CHILDREN 

Acute Thymitis 

Acute thymitis is a rare affection, generally occurring only in young 
infants. The etiology is obscure: in some cases a history of naso- 
pharyngeal infection is elicited. It is also claimed that thymitis may 
develop secondarily to a systemic pyemic process or by extension of 
inflammation from adjacent structures. The symptomatology is usu- 
ally indefinite, except where the thymus attains an enormous size 
and gives rise to pressure symptoms on the larnyx, esophagus, and the 
large blood vessels in the mediastinum, etc. The case presently to be 
related may offer a general idea of the puzzling symptom complex. 
The baby was four weeks old, normal at birth and nursed by the 
mother. It was circumcised when eight days old, and did well very 
soon after. The day before coming under my observation it was very 
restless, and towards evening, while at the breast, suddenly dropped 
the nipple, gave a sharp loud cry, snapped the jaws tightly together, 
and seemed to lose consciousness. A neighboring physician who was 
immediately consulted, did not venture to express a definite opinion, 
but prescribed calomel and an intestinal irrigation. The next day I 
found the baby in the following condition. The baby looked well 
nourished and otherwise normal in appearance. It lay perfectly still 
with its eyes widely open. There was neither rigidity of the neck, 
nor any other sign (Brudzinski, Kernig, etc.) of disease of the nervous 
system. The respirations ranged between 70 and 80 per minute, and 
were acompanied by an expiratory moan. The heart beat ranged 
between 120 to 130 per minute. Both the lungs and heart. were ab- 
solutely free from any abnormal physical signs. The liver and spleen 
were normal in size. The urine although greatly suppressed in the 
beginning, showed no abnormal constituents. There was relative con- 
stipation, but the bowels moved with enema. The abdomen was soft 
and free from any tumefaction. The blood was negative except for 
a high leucocytosis. The temperature was below 100° F., but rose to 
102° and 103° F. a few days later. The jaws remained somewhat rigid, 
and the baby refused to nurse at the breast. He swallowed milk 
dropped in his mouth, apparently with ease, in the first three or four 
days of his illness, but with difficulty towards the end. At this time 
attacks of asphyxia and continued cyanosis also set in. The baby 
was ill six days and died without a struggle. The two learned ped- 
iatrists whom I consulted on the case, like myself, failed to arrive at 
a correct diagnosis. We all suspected a toxic condition of the blood, 
but never thought of the thymus gland. Some time later I had the 
opportunity to discuss the case with Dr. Charles G. Kerley, who 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS 567 

kindty informed me that he had seen a few cases of the kind at the 
Babies' Hospital and that postmortem examination disclosed acnte 
inflammation of the thymus gland. I firmly believe we were dealing 
with just such a case. 

Acute thymitis sometimes leads to suppuration of the gland. 

Chronic Thymitis 

Chronic thymus disease is variously attributed to lung and heart 
disease, pertussis, rubeola, diphtheria, scarlatina, asphyxia neona- 
torum, tuberculous and syphilitic processes, and malignant growths, 
but excepting the last three etiologic factors, the manifestations pro- 
duced by the other causes are undoubtedly only transient in character. 
The same is true of atrophy of the thymus associated with protracted 
malnutrition. Indeed, it has been shown that the atrophied gland in 
emaciation is often regenerated on restoration of the body weight. I 
am inclined to believe, therefore, that genuine hypo- or hyperplasia of 
the thymus is due either to a primary congenital anomaly of the thy- 
mus, or develops later secondarily to alterations in the thyroid or other 
lymphatic gland. 

Whatever the cause, the clinical syndromes arising from the effects 
of hypo- or lryperplasia of the thymus are not as difficult of recognition 
as was formerly believed. As already stated the functions of the 
thymus and thyroid glands are closely correlated, so that hypoplasia 
of the thymus by inducing also a reciprocal diminution in the thyroid 
secretion produces not only an arrest of growth and frailty of the 
bones and general debility, but also lowered mental capacity as ex- 
emplified in infantilism, more especially in the Brissaud and Lorain 
types. 

The clinical signs of hyperplasia differ with the degree of the thymic 
enlargement and the functional activity of the thymus. Not every 
case of thymus hypertrophy is necessarily associated with increased 
function of the gland. The latter may, for example, owe its enlarge- 
ment to a growth destroying the medullary substance of the gland, 
and thus be incapacitated rather than hyperactivated. Even where the 
thymus secretion is excessive, the symptoms engendered vary greatly. 
By corresponding increased activity of the thyroid the clinical picture 
may be limited to that observed in hyperthyroidism, i. e., tachycardia, 
insomnia, change in disposition, abnormal perspiration, and often also 
a mild degree of exophthalmos and possibly struma. 

In another group of cases of hyperplasia of the thymus careful 
examination of the child fails to reveal any definite manifestations 
of a pathologic entity, except possibly a few signs of anemia with 



568 DISEASES OF CHILDREX 

adipositas, rachitis, or " scrof ulosis, " but this notwithstanding, death 
may occur without any apparent reason as the result of slight causes 
(e. g., serum injection, narcosis, slight operations, etc.) which produce 
physical excitement or shock and are usually of no consequence in 
healthy children. This condition is generally spoken of as status 
lymphaticus or lymphatism. Unfortunately, we have no characteristic 
symptoms by means of which this condition may be diagnosed during 
life and nothing characteristic is found at necropsy. 

Finally, in another group of cases hyperplasia of the thymus percus- 
sion reveals marked dulness over the upper portion of the sternum 
particularly to the left as low as the second rib and often also to the 
back between the scapula?. It is in addition distinguished by the 
presence of swollen lymph glands in the lateral lower region of the 
neck, which may sometimes be seen to continue deeply down between 
the clavicle and side of the sternum. If the hypertrophy is of long 
standing we readily detect secondary manifestations, such as dilata- 
tion of the veins of the neck, dislocation of the heart, accentuation of 
auscultatory signs of the heart and lungs and arching and distention 
of the thorax. The thymus gland may occasionally be felt in the 
middle line above the incisura sterni as an arched elastic swelling, 
which may ascend upward to the thyroid gland. Furthermore, the 
thymus enlargement is distinctly discernible by means of the Roentgen 
rays. The clinical signs differ, of course, with the degree of mechan- 
ical encroachment upon the adjacent structures (thyroid, blood ves- 
sels and nerves, trachea and bronchi) and secondary involvement of 
the heart and lungs. As a rule, the symptomatology is essentially 
that of cardiac asthma, so-called, and is generally spoken of as asthma 
thymic u m. The child is suffering from a persistent cough and other 
signs of bronchitis, marked dyspnea, cyanosis or marked pallor of 
the face and, off and on, with acute turgescence of the enlarged thy- 
mus, it is attacked by paroxysms of asphyxia which not rarely termi- 
nate fatally. Pott,* who has frequently observed the course of these 
fatal attacks of asphyxia, describes them as follows. The children 
bend their heads suddenly backward (which position, by the way, by 
producing a marked lordosis of the cervical region of the spine and 
thus increasing the pressure of the thymus against the trachea greatly 
aggravates the laryngospasm), and make soundless, gasping inspira- 
tory movements. The eyes are turned, the face is blue or black, the 
cyanotic tongue is impacted between the jaws, the veins of the neck 
are distended, the hands are clinched, the forearms are pronated 
and abducted, the legs are stiff and extended, the large toes are 



e Graetzer and Sheffield's Practical Pediatrics, p. 296. 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS 569 

abducted and flexed, and the spine is arched strongly backward. 
The pulse, heart's action, and heart sounds cease immediately with 
the onset of the paroxysm, and after a few futile respiratory efforts 
the face turns ashy in color and in a minute or two the child is a 
corpse. Pott believes to have felt the vocal cords snugly together 
in the median line. He nevertheless maintains that death is caused 
by heavt failure and not by closure of the glottis, for on two occa- 
sions he performed immediate tracheotomy by one incision without 
any relief. This view is not shared by all observers, and Biedert, for 
example, is of the opinion that closure of the glottis, through suffo- 
cation stasis in the heart and thymus might be responsible for the 
onset of such an attack and its grave result. Of course, not all at- 
tacks terminate immediately fatally. Some time ago I had the op- 
portunity, for several weeks, to watch a five-months-old infant 
afflicted with an apparently congenital hyperplasia of the thymus. 
The family history was negative as regards syphilis and tuberculosis. 
The father, a French artist, was in perfect health, the mother was 
subject to arthritis with slight valvular heart disease. The older 
child, who is now ten years old, was for four months suffering from 
spasmodic pyloric stenosis. The infant under consideration weighed 
about 5 pounds at birth and failed to gain though breast-fed for the 
first three months of its life. It was noticed immediately after birth 
that he was very pale and cyanotic, had some difficulty in breathing, 
coughed a little and had a husky cry. Gradually these symptoms 
became worse and attacks of bronchitis with marked dyspnea set in, 
during which the baby would repeatedly be seized by convulsions 
with loss of consciousness. The family physician diagnosed it as 
asthma, while a very learned pediatrist decided that they were deal- 
ing with spasmus glottidis supervening faulty feeding. The child's 
condition got gradually worse, notwithstanding the correction of diet 
and administration of antispasmodics, etc. When I saw it the clini- 
cal picture resembled pulmonary edema, but there were no signs of 
primary heart or kidney disease and the history of the case and the 
distinct hoarseness certainly pointed to some form of immediate 
obstruction in the upper respiratory tract — most probably primary, 
nay congenital, since it was manifested at birth. There was no diffi- 
culty to exclude asthma, as this disease is invariably associated with 
remissions and would at least temporarily yield to antiasthmatic 
remedies which in this case were given a fair trial. Neither did the 
diagnosis of spasmus glottidis appeal to me. Here the infant is free 
from dyspnea, etc., between each paroxysm, and certainly does not 
get worse on a suitable diet. Going over the case more carefully I 



570 



DISEASES OF CHILDREN 



detected undue dulness over the upper portion of the sternum, marked 
dilatation of the veins in the neck, fulness of the neck over the inter- 
clavicular notch — all signs and symptoms which were quite suggest- 
ive of thymus hypertrophy. I therefore suggested a Roentgen-ray 
examination, which promptly confirmed my diagnosis. The infant 
was in too delicate a condition to undergo thymectomy, and his par- 
ents — rightly — hesitated to consent to this procedure. The infant 
was soon relieved of its agony during a paroxysm of asphyxia. 

Treatment. — Acute thymitis, if detected early may occasionally be 
arrested in its progress by an ice bag, and in strong infants a few 




Fig. 164. — Precocious child eight years old; began to menstruate when about five 
years old (hyperpituitaria?). 



leeches over the manubrium sterni, and internal administration of 
calomel. In chronic thymus hypertrophy, if severe in character, 
partial or even complete removal of the thymus is absolutely indis- 
pensable. Before resorting to an operation, however, we must as- 
certain that we are not dealing with a syphilitic condition, which 
may be remedied by antisyphilitic medication. Sudden attacks of 
asphyxia calls for prompt tracheotomy or intubation and antispas- 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS 571 

modics (bromides, codeine). In hypoplasia of the thymus, some bene- 
fit may possibly be derived from internal administration of thymus 
gland, from 10 to 30 grains daily. 

Disease of the Pituitary Gland, or Hypophysis Cerebri 

CHypeepituitaria; Hypopituitaria ; Dystrophia Adiposogenitalis, 

Frohlich) 

The pituitary body consists of an anterior, middle and posterior 
portion, and is situated at the base of the brain, resting upon and 
slightly surrounded by the sella turcica. Disturbances in the function 
of the anterior portion of the hypophysis give rise to gigantism in 
children and acromegaly in adults, while disturbances in the function 
of the posterior (or both anterior and posterior) portion of the hypo- 
physis leads to dystrophia adiposogenitalis, a clinical syndrome first 
described by A. Frohlich in 1911. This clinical entity is manifested by 
retarded growth and development, excessive adipositas, sexual in- 
fantilism, atrophy of the sexual glands, polyuria, subnormal tempera- 
ture, sluggish metabolism, and high tolerance for carbohydrates (ex- 
cessive amounts of sugar fail to produce glycosuria). 

In treating pituitary disease it is essential first of all to determine 
by exact Roentgen-ray examinations, whether or not a hypophyseal 
tumor is being dealt with. If this be so, operative interference is 
indispensable, and is nowadays executed with a fair amount of suc- 
cess. In the absence of a tumor, pituitary feeding should be resorted 
to, particularly in cases of hypo- and apituitarism. 



CHAPTER XI 
DISEASES OF THE KIDNEYS, BLADDER, ETC. 

Nephritis Acuta 

Acute nephritis is most frequently met with in association with 
acute infectious and contagious diseases, especially scarlatina, diph- 
theria, tonsillitis, influenza, and pneumonia. Less frequently it occurs as 
a result of exposure to wet and cold; of structural alterations of the 
skin, e. g., extensive burns; of ingestion of certain irritants to the 
kidneys, e. g., cantharides, potassium chlorate, aspiclium, etc., ether 
or chloroform inhalation, and, finally, not rarely it is observed in 
infants suffering from gastroenteric affections. The aforementioned 
causes usually operate upon both kidneys, so that both kidneys are 
equally affected. The lesion may, however, remain limited to one 
kidney where the disease is caused by direct, unilateral trauma (di- 
rect violence, calculus, etc.). The seat of the kidney lesions varies 
somewhat with the cause. For example, the glomeruli {glomerular 
nephritis) are mcst severely involved in scarlatina, while in diph- 
theria we most commonly find degenerative changes in the renal tubules 
{degenerative or parenchymatous nephritis). But no particular form 
of acute nephritis is peculiar to a given cause. In severe cases the 
kidneys are greatly increased in volume and weight. The surface 
is smooth and the capsule readily removable. The renal cortex is 
either uniformly reddened or pale and mottled with red. The tubuli 
uriniferi are partly or completely obstructed by large granular epithe- 
lial cells, blood corpuscles and fibrin. In the early stage of the 
disease the interstitial tissue shows no alteration; in protracted cases, 
however, this tissue may suffer very severely. In this event the proc- 
ess is often spoken of as productive or interstitial nephritis. 

Consonant with the etiologic factors we distinguish a primary 
and secondary form of acute nephritis, but, except for some slight 
difference in the onset (it being more sudden in primary nephritis), 
the symptomatology is practically the same in both varieties. The 
child complains of headache, backache, dizziness, nausea and chilli- 
ness, occasionally vomits, and in severe forms shows other symptoms 
of grave constitutional disturbance. Not infrequently attention to 
the illness is not attracted until the appearance of pronounced anemia 

572 



DISEASES OF THE KIDNEYS AND BLADDER 



573 



and puffiness of the eyelids, or, especially in infants, the occurrence 
of partial or total suppression of urine with or without uremic symp- 
toms. Examination of the urine discloses more or less marked al- 
teration in its constituents. Chemically, the urine almost invariably 
reveals the presence of a variable amount of albumin, and, micro- 
scopically, casts of all sorts, especially hyaline, red and white blood cor- 
puscles, epithelium, detritus, etc. The urine is usually acid, and its 
specific gravity high, the latter being, of course, most marked when 
the quantity is very small. The excretion of urea is diminished. In 





Fig. 165. — Acute nephritis with general 
anasarca in a four-month-old infant. Note 
"pitting" on pressure with finger. 



Fig. 166. — Same case as Fig. 165 
three weeks later. 



severe inflammation of the kidneys the urine contains a large quantity 
of blood (hemorrhagic nephritis), and is dark-red or smoky in color. 
As already alluded to, the onset of nephritis often escapes detection. 
This is especially true in the secondary form. Hence the importance 
of systematic examination of the urine during the course of acute 
communicable diseases. It is well to remember, however, that not 
every albuminuria is of nephritic origin. A small quantity of albumin 
and a few casts are not rarely found in acute febrile diseases (e. g., 



574 



DISEASES OF CHILDREN 




DISEASES OF THE KIDNEYS AND BLADDER 575 

in the beginning of scarlatina) without kidney lesions and are only 
transitory in nature. 

Cases running a favorable course begin markedly to improve after 
about two weeks. The albumin diminishes, the urine increases in 
quantity, becomes light and clear, and the microscopic abnormal 
constituents subside. Edema, if present, is slight, and usually limited 
to the eyelids and rapidly disappears with the improvement of the 
other symptoms. 

Less favorable cases are of longer duration. From day to day 
the edema assumes wider dimensions, involving the dorsi of the feet, 
the legs, the genitalia, and, if not checked, the serous effusion may 
rapidly fill the abdominal and thoracic cavities. In the majority of 
instances, however, gradual recovery from the immediate attack oc- 
curs, although in these cases a relapse must always be apprehended. 

Another group of cases is characterized by great diminution of 
urine (oliguria) or total suppression and consecutive uremia. The 
latter is manifested by intense headache, dizziness, vomiting, dimness 
of vision up to total blindness, disturbance of hearing, slight twitch- 
ing up to repeated attacks of severe convulsions, slow, irregular 
pulse, dyspnea, somnolence, sopor and possibly coma and death. 

The incipient symptoms of nephritis offer no reliable indications 
as to the further course of the disease. Scarlatinal nephritis, for ex- 
ample, ushers in with vomiting, intense headache, convulsions, local 
or general dropsy, and yet often clears up completely within two or 
three weeks; and, conversely, nephritis may set in insidiously, appar- 
ently free from any alarming sj^mptoms, and, nevertheless, proceed 
a very protracted course and possibly lead to permanent degeneration 
of the kidney structures. Furthermore, relapses may complicate mat- 
ters, often when recovery is imminent. 

The prognosis, therefore, should always be guarded, even though 
the general condition of the patient is good. Even in mild cases 
untoward complications are apt to supervene. Serous effusions in 
internal cavities are not rare. This is true especially of ascites, less 
frequently of pleural or pericardial effusions. The heart rarely es- 
capes involvement. Hypertrophy of the heart is quite common, and, 
if the nephritis runs a protracted course, dilatation of the heart may 
prove a very dangerous complication, particularly in view of the 
secondary pulmonary edema, which is very prone to occur in such 
cases, and often proves fatal. Extensive anasarca with scanty urine, 
especially if ascites is associated with hydrothorax, greatly mars the 
prognosis. As further complications we may mention uremia, pneu- 
monia, edema of the glottis, severe intestinal catarrh, more rarely 



576 DISEASES OF CHILDREN 

peritonitis, pericarditis and endocarditis (more frequent in scarlatinal 
nephritis). Notwithstanding, however, the great array of complica- 
tions, immediate death from acute nephritis, especially the primary 
variety, is not common. The death rate ranges from between 5 and 
20 per cent, the variation depending upon the primary cause, mode 
of treatment and severity of the complications. A great many pa- 
tients who survive the acute stage remain invalided for life. As 
we shall see later, gradual transition from acute into chronic neph- 
ritis is not of uncommon occurrence. Convalescence is often pro- 
longed for weeks and months, and even without permanent injury to 
the kidneys albumin may recur in the urine from time to time for a 
period of a year or two longer and continue to undermine the child's 
constitution. 

Treatment. — Every case of nephritis, be it ever so mild, should be 
taken seriously, and kept under strict observation not only during 
the active stage of the affection, but for many months after. During 
the acute stage perfect rest in bed should be enjoined and the diet 
limited to bland articles of food free from salt, preferably milk in 
moderate quantity with strained oatmeal or barley, zwieback with 
sweet butter, stale bread with a little apple sauce, and occasionally 
a little chicken soup. In the absence of edema the drinking of Avater is 
not limited, but, otherwise, the partaking of water should be restricted 
to a few tumblerfuls of Vichy or lithia water per day. As the con- 
dition improves the dietary may be augmented by the addition of 
freshly boiled — without salt — vegetables, such as carrots, spinach, 
cauliflower, fresh green peas, etc., stewed fruit, and freshly boiled 
whitefish. The bowels should be kept open by an occasional dose of 
calomel followed by citrate of magnesia and by daily high intestinal 
irrigation. Where the excretion of urine is greatly reduced and the 
dropsy marked, energetic measures should be instituted without de- 
lay to relieve the kidney. This should be attempted, not, as is fre- 
quently advised, by means of active diuretics, which only help to in- 
crease the renal congestion, but by stimulating the activity of the 
skin and bowels and allaying the irritation of the kidney. For this 
purpose we resort to hot packs (105° P.), hot baths (103° F.), and 
hot (110° F.) rectal enemas (to be retained as long as possible) or 
the Murphy drip. These may be repeated every six hours. Perspira- 
tion may be stimulated by small quantities of hot water, or hot lemon- 
ade. In hemorrhagic nephritis small doses of ergot act beneficially. 
Camphor will be found valuable to counteract collapse, and should 
be administered hypodermically in the form of sterilized camphor- 



DISEASES OF THE KIDNEYS AND BLADDER 577 

ated oil. Excessive irritability of the nervous system should be com- 
bated by means of the bromides and chloral. 

By carefully following the aforementioned directions, uremia is 
of rare occurrence. Uremic convulsions should be controlled by 
chloroform inhalation, hypodermic injection of morphine and atro- 
pine (for a child two years old % 2 grain of morphine and % o grain 
of atropine, if necessary to be repeated once after two hours), and 
where these therapeutic measures fail, by lumbar puncture. 

Children recovering from nephritis should not be exposed to the ill 
effects of overfeeding, overexertion, and exposure to marked atmo- 
spheric changes. They should wear light woolen underwear, and, finan- 
cial means permitting, should spend the winter following an acute 
attack of nephritis in a warm climate. 

To overcome the remaining anemia, iron and cod liver oil will be 
found of service. 

Nephritis Chronica 

In the majority of instances chronic nephritis develops as a sequel 
of the acute affection of the kidneys. The parenchyma or interstitial 
tissue, or both, remain permanently impaired. On the one hand, we 
may find the kidneys greatly enlarged, the cortical portion increased 
in volume, its surface white or pale-yellow — the large white kidney, 
or parenchymatous nephritis; on the other, the whole organ is reduced 
in size, the capsule firmly adherent, and the surface irregular and 
nodular — the granular or cirrhotic kidney, or interstitial nephritis. 
Amyloid degeneration is another form of chronic nephritis in child- 
hood. It is usually associated with amyloid degeneration of the liver 
and spleen, and ordinarily occurs secondarily to suppurative processes 
of the bones or joints. Occasionally chronic nephritis is encountered 
in connection with congenital malformations of the kidneys, or as a 
result of hereditary syphilis, tuberculosis, and heart disease. 

In the early stages of chronic nephritis the diagnosis rests princi- 
pally upon the chemic and microscopic findings in the urine. (See 
p. 574.) In parenchymatous nephritis the quantity of urine is normal 
or diminished, the specific gravity normal or increased, the albumin 
content high, and the color cloudy, brownish yellow or bloody. In 
interstitial nephritis the quantity of urine is increased, the specific 
gravity low, the albumin content low (occasionally no albumin), and 
the color clear, and pale. In amyloid degeneration the urine is rich 
in serum albumin and globulin. Its quantity is often increased. Casts 
in the urine are present in all varieties. 

Where laboratory facilities are at our command, it is of great diag- 



578 DISEASES OP CHILDREN 

nostic and prognostic advantage to determine the functional capacity 
of the kidneys by means of the phenolsulphonephthalein test and the 
"two-hour" renal test. 

With further advance of the disease, the gradually appearing profound 
anemia, digestive and respiratory disturbances, local and general 
dropsy, and cardiac debility readily disclose the underlying condition. 
Toward the end of life the symptoms resemble greatly those of non- 
compensating heart disease. 

Parenchymatous nephritis offers the worst prognosis, death usually 
setting in within a year from the appearance of the secondary symp- 
toms. The course of interstitial and amyloid nephritis is much more 
protracted, and cases of amyloid kidney are on record that markedly 
improved on removal of the suppurative bone affection; however, com- 
plete recovery is practically out of the question. 

Treatment. — Under suitable treatment (except in parenchymatous 
variety) life may be prolonged for many years. As in acute nephritis, 
the diet should be free from salt, but otherwise should be more liberal. 
Older children may live on a mixed diet; the following foodstuffs, 
however, are to be exempt from the list: liver, ham, brains, kidneys, 
beef -juice, and beef extract, soups, coffee, liquors and spices. All meats, 
eggs and fish should be taken sparingly. Whenever possible, the 
child should live in a warm climate. Outdoor life and very light 
exercise are desirable. Daily warm baths with gentle massage act bene- 
ficially. With the appearance of dropsy, dyspnea, or other grave symp- 
toms, the patient should be put to bed and treated in the manner out- 
lined under "Acute Nephritis" and "Chronic Heart Disease" (q. v.). 

Hematinics, in small doses, and other tonics in the form of cod 
liver oil, nux vomica, and digestants are in order as necessity arises. 
Excessive dropsical effusions should be relieved by active catharsis, 
alkaline diuretics, and heart stimulants (digitalis, diuretin), in addi- 
tion to the therapeutic measures recommended in dropsy accompany- 
ing acute nephritis. 

In protracted cases, considerable benefit may be derived from 
Karell's diet, which consists of 60 to 200 c.c. of skimmed milk every 
four hours during the day, with exclusion of every other food and 
drink. In some cases protein milk may be tried. Splitting or extirpa- 
tion of the kidney capsule (Edebohls' operation) will often prolong life. 

Nephrolithiasis 

(Stones in the Kidney, Renal Calculi) 
Eenal calculi in children give rise to symptoms identical with those 
observed in adults. Thus, sudden attacks of pain in the lumbar 
region, radiating downward along the course of the ureters, groins, 



DISEASES OP THE KIDNEYS AND BLADDER 



579 



and, in the male, to the testicles. The attacks are usually associated 
with nausea, vomiting, and sometimes convulsions and collapse. The 
urine is passed frequently, in small quantities, and contains blood and 
pus cells. The urine, however, may appear normal if it is excreted 
from the healthy kidney only; or there may be complete anuria if both 
ureters are simultaneously obstructed. 

Treatment. — Where the stones remain impacted in the ureter, the 




Fig. 167. — Oval calculus in left ureter and one just emerging from lower pole of left 
kidney in a child nine years old. 



580 DISEASES OF CHILDREN 

condition is apt to become very grave in consequence of supervening 
hydronephrosis, pyonephrosis, or pyelonephritis. In this event we 
are often obliged to resort to surgical interference. Otherwise symp- 
tomatic treatment usually suffices to effect marked improvement or 
even a cure. Alkalies (piperazine !) should be administered in uric acid 
concrements ; sodium phosphate in oxalic acid, and citric acid and acetic 
acid in pJiosphatic concrements. The diet should be bland (avoidance of 
meat), and metabolism enhanced by digestives, mild laxatives (% ounce 
of Margarita water in hot water every morning), moderate exercise, 
hydrotherapy and massage. To relieve an attack we resort to ano- 
dynes (morphine and atrophine hypodermically or a codeine suppos- 
itory), hot baths and hot poultices. 

Right-sided nephrolithiasis may be mistaken for acute appendicitis. 
But in addition to the pathognomonic signs of appendicitis it will 
generally be found that the patient suffering from appendicitis keeps 
perfectly still in bed during the acute stage of the attack, whereas, the 
nephrolithiasis patient is quite active, moving from place to place while 
the pain is most severe. 

An x-ray examination is often decisive in the diagnosis between 
nephrolithiasis and appendicitis. In older children cystoscopy will 
greatly aid in the diagnosis. (See "Uric Acid Infarcts".) 

Pyelitis," Pyelonephritis, Pyelonephrosis 

Inflammation of the pelvis of the kidney and contiguous structures 
with consecutive suppuration usually occurs, as first demonstrated by 
Escherich, as a result of infection by the Bacillus coli communis (either 
secondarily to enteric infection, or by systemic infection through some 
lesion in the intestinal mucosa) ; as a sequel of infectious diseases, 
such as scarlatina, diphtheria, variola, or pyemia, or by extension of 
a suppurative process from the neighboring tissues or organs, e. g., 
perinephritic abscess, cystitis, colicystitis, (q.v), purulent vulvo- 
vaginitis and also as a result of direct injury to the lining mucous mem- 
brane, e. g., renal stones. It is also met with in connection with con- 
genital malformations of the kidneys or ureters, renal tuberculosis and 
tumors. The pyelitis may be unilateral (when due to a local cause) or 
bilateral. 

The symptomatology of pyelitis varies greatly with the cause and 
the course it pursues. In acute cases there are rigors, high and fluc- 
tuating temperatures, frequent and scanty urination, pain in the lum- 
bar region (often elicited also on palpation) and, above all, pyuria. 
The morphologic constituents of the urine vary with the degree of 



*See also Pyelocystitis. 



DISEASES OF THE KIDNEYS AND BLADDER 581 

involvement of the kidneys, ureters and bladder. In a large number of 
cases the pyelitis is masked by the primary affection and can only be 
detected by examination of the urine — which should invariably be 
done where irregular, high fever, without apparent cause, prevails. 
Cases pursuing a chronic course are ordinarily free from febrile ex- 
cursions, but the children are pale or waxy in color, complain of head- 
ache, lassitude or cardiac palpitation and other symptoms of wasting 
diseases. Pyonephritis with pus retention (pyonephrosis) often gives 
rise to a palpable tumor. 

Where the cause is removable, and prompt treatment is instituted, 
the pyelitis may entirely disappear and leave the kidney uninjured. 
Otherwise the prognosis, as to complete recovery, is bad. The prog- 
nosis as to life depends entirely upon the exciting cause and compli- 
cations, nephritis and exhaustion forming the principal sources of 
danger. 

Treatment. — The aim of the treatment, therefore, should be to avoid 
nephritis by early elimination of the fundamental disease, and pre- 
vention of recurrences of the attacks. The details of such treatment are 
fully outlined when speaking of the disease in question. Otherwise 
the treatment is symptomatic. Kest in bed and liquid diet during the 
acute course of the disease. Urotropin, from 3 to 5 grains every four 
hours, is indicated in all cases. The urine should be rendered alkaline 
and as aseptic as possible. This is best accomplished by a liberal supply 
of water, alkaline diuretics such as potassium citrate (gr. x t. i. d.) in 
addition to the hexamethylenamine. Of late attempts have been made 
to cure chronic pyelitis by irrigating and draining the renal pelvis. 
Kretschmer* and Helmholz claim to have cured a number of cases of 
pyelitis by injecting into the renal pelvis 1 c.c. to 5 c.c. of a 0.5 per cent 
of silver nitrate solution. The injections may be repeated once or twice, 
until the urine cultures become sterile. The results as a whole are not 
very encouraging. The same is true of the administration of vaccines. 
Pyonephrosis calls for surgical interference. (See also "Pyelocysti- 
tis".) 

Hemoglobinuria 

Hemoglobin or methemoglobin in the urine is occasionally observed 
in infants and older children, either as a result of poisoning by phos- 
phorus, potassium chlorate, carbolic acid, etc., or in connection with 
severe burns, acute and chronic infectious diseases, such as exanthe- 
mata, malaria, and hereditary syphilis. The urine is mahogany- 
brown or black in color, greatly resembling bloody urine. Micro- 
scopically, however, it shows the presence of blood coloring substance 



*Jour. Am. Med. Assn., Nov. 13, 1920. 



582 DISEASES OF CHILDREN 

only, but no blood corpuscles. The spectroscope discloses bands of 
hemoglobin. The attacks of the hemoglobinuria are of brief duration 
(sometimes last but a few hours), and are manifested by debility, 
chilliness, cyanosis, and sometimes high fever. These symptoms dis- 
appear as the urine clears up, which ordinarily occurs within a few 
hours or days. Occasionally the hemoglobinuria appears in parox- 
ysms {paroxysmal hemoglobinuria) without any discernible cause or 
after exposure to cold or undue fatigue. 

By rest in bed, liberal supply of liquids, and attention to the excit- 
ing cause, the hemoglobinuria subsides without any serious conse- 
quences. (See "Epidemic Hemoglobinuria".) 

Orthotic, Lordotic, Cyclic or Functional Albuminuria 

As the term (orthotic: standing up) indicates, the disease is 
characterized by the presence of albuminuria after the patient has 
been up and around (usually several minutes after the erect posture 
has been assumed) and by its absence while he is perfectly at rest. 
It is observed especially in delicate children of from five to fifteen 
years of age, and seems to have nothing in common with organic 
kidney disease. It has been observed that children suffering from 
lordosis in the upper lumbar spine are especially prone to be affected 
by the disease — the spinal deformity by pressure upon the kidneys ap- 
parently interfering with the renal circulation. A family predisposi- 
tion has been traced in some cases, and a history of scarlatina and 
diphtheria in others. The urine is ordinarily free from abnormal 
morphologic constituents, the opposite, of course, being the case in 
true renal disease. 

Treatment. — Under suitable treatment, which is essentially the same 
as in the early stage of chronic nephritis plus correction of lordosis, 
if there be any, the albuminuria often disappears for a time, but may 
return after a shorter or longer interval (intermittent form). Not- 
withstanding the continuance of the albuminuria for many years, the 
system is very little affected by it, and the prognosis as to life is good. 
Transition of cyclic albuminuria into nephritis, however, is on record. 

Tumors of the Kidney 

Aside from tuberculosis and syphilis, which have been discussed 
elsewhere, the kidneys are occasionally the seat also of benign and 
malignant neoplasms. The benign tumors (adenoma, fibroma lipoma, 
cysts, etc.) owing to their very slow growth, generally escape observa- 
tion, and are often found postmortem in children who during life never 



DISEASES OF THE KIDNEYS AND BLADDER 



583 



manifested signs of kidney growths. To a great extent this is trne 
also of malignant tumors (sarcoma, carcinoma, myosarcoma, and ad- 
enosarcoma) in their early stages of development, since at this period 
the tumor is barely palpable, and the two additional characteristic 
signs of malignant kidney growths (i. e. hematuria and cachexia) are 
present only in a small percentage of such cases (usually carcinoma) 
and are encountered also in a number of other wasting and hemorrhagic 
diseases. Moreover, hematuria is often absent during the late stage, 
when the tumor encroaches upon the ureter and obstructs the flow of 
urine from the affected kidney. Ascites is a frequent symptom, and 
the colon is usually pushed in front of the tumor. As the growth ad- 




Fig. 168. — Adenosarcoma of right kidney in a boy twenty-seven months old, occupy- 
ing almost the entire abdomen. 



vances it spreads in all directions displacing the liver, spleen, heart 
and lungs, and occupies the entire abdominal cavity. Not rarely, 
secondary metastases are formed in the other kidney, in the liver, 
spleen, intestines and retroperitoneal glands, and by pressure upon 
the ureter, give rise to hydronephrosis. Roentgen-ray examination is 
helpful in the diagnosis. 

Treatment. — Unless operated upon early — which treatment should 
invariably be recommended — the children usually succumb to pro- 
gressive emaciation and exhaustion within about a year from the time 
the tumor makes itself felt. As the majority of the growths are of 
antenatal origin, nothing can be done in the w T ay of prophylaxis. 



584 DISEASES OF CHILDREN 

Cystitis, Colicystitis 

(Pyelocystitis) 

Inflammation of the bladder may occur as a primary or secondary 
disease. Primary cystitis is extremely rare in children, more especially 
in infants, since the principal cause — direct mechanical injury of the 
mucous membrane by surgical instruments or other foreign bodies — is 
but rarely operative in young children. On the other hand, secondary 
cystitis is of comparatively frequent occurrence, more particularly in 
girls, and may arise from a great many causes, the most important be- 
ing infectious diseases (diphtheria, scarlatina, etc.), kidney and blad- 
der disease (calculi, pyelitis, tuberculosis, tumors, etc.), cerebrospinal 
affections (atony and overdistension of the bladder with consecutive 
inflammation by decomposed urine), intestinal diseases (invasion of the 
bladder by the colon bacillus — {Colicystitis), and diseases of the vagina 
and urethra, especially of gonorrheal origin (by extension of the 
inflammation). Cystitis may follow chemical irritation (from over- 
doses of cantharides, balsams, liquors, etc.), exposure to cold (sitting 
on cold stones, etc.), and direct external violence. 

The lesions in the bladder may range from simple localized redness 
to extensive ulceration of the mucous membrane and pseudomem- 
branous deposit. In cases of long standing the inflammation is prone 
to spread to the ureters and kidneys. In chronic cystitis the mucosa 
assumes a gray, pigmented color, becomes greatly hypertrjophied, 
and is covered by mucopurulent masses. 

In accord with the severity and extent of the lesion cystitis may be 
manifested by mild or grave symptoms. The latter are most pro- 
nounced in primary cases, in those associated with infectious dis- 
eases (e. g., diphtheria), and in infection by the colon bacillus. In mild 
cases the symptomatology consists of painful and frequent micturi- 
tion, sensitiveness over the region of the bladder, sometimes rectal 
tenesmus and excoriation of the urethral orifice and of the contiguous 
structures. The urine is voided in small quantities, sometimes only 
a few drops at a time, and contains mucous shreds, bladder epithe- 
lium, pus corpuscles, blood corpuscles, and numerous bacteria. The 
urine in simple cystitis is neutral or alkaline, cloudy and dark red, 
and may contain pieces of membrane, if the cystitis is of diphtheritic 
origin. On the other hand, in colicystitis the urine is acid in reaction, 
and in addition to the aforementioned constituents we find a large quan- 
tity of pus and some albumin, and, not rarely, there are marked con- 
stitutional disturbances, such as vomiting, chills, irregular fever, and 
sometimes convulsions (particularly if anuria exists). The local 



DISEASES OF THE KIDXEYS AND BLADDER 585 

symptoms also are much more pronounced. If left to run its course, 
the condition is not rarely aggravated by the concurrence of nephritis 
and pyelonephritis (q.v.) which may lead to fatal termination. 

Treatment. — As it is not ahvays possible in the beginning to foresee 
the eventual course of the disease, and as the tendency even of mild 
cases toward chronicity is great, it is essential not to trifle with the 
affection, but promptly to employ all such therapeutic measures as 
will insure its early arrest and ultimate cure. The patient should be 
put to bed and on a mild diet (milk and Vichy water, milk gruel, 
fermented milk, and well-boiled vegetables). All spices, alcoholic 
beverages, coffee, and tea should be prohibited. To relieve pain, 
hyoscyamus is the remedy par excellence. It may be combined with 
citrate or acetate of potash and small doses (3 grains every four hours) 
of hexamethylenamine. Warm Priessnitz compresses are also of value. 
Where the pain persists, a suppository of codeine and extract of 
belladonna will be found to act well. With subsidence of the acute 
symptoms — usually after a week or two — it is advisable to begin to 
irrigate the bladder (under the most careful aseptic precautions) with 
a warm solution of boracic acid (5 i to i) or of nitrate of silver or 
potassium permanganate (1/2000 or 1/1000). From % pint to 1 quart 
of the solution may be used for each treatment, and the irrigation may 
be repeated once a day or every other day. In mild cases boric acid 
solution (1 dram to 1 quart) alone may suffice. 

Under this method of treatment the majority of cases of cystitis 
will recover in from four to eight weeks; provided, of course, the 
primary cause can be detected and removed. 

Transition of simple acute cystitis into chronic is by far less com- 
mon in children than in adults. The possibility of the disease being 
tubercular in nature, however, should always be borne in mind. (See 
p. 457.) For diagnostic purposes F. Hinman (Am. Jour. Dis. Child., 
May, 1919) strongly advocates cystoscopy and ureteral catheteriza- 
tion in all chronic cases, irrespective of sex or age of the child. 



Potassii Acetatis 


3i 


4.00 


Ext. Hyoscyami Fl. 


m. xvi 


1.00 


Ext. Tritici Eepens Fl. 


3i 


4.00 


Inf. Uva3 Ursi 
M. 

S. — One teaspoonful in 


q. s. ad 5 ii 


60.00 


water every four hours, 


for a child five years old 


(Simple cysti 


tis.) 



In subacute or chronic colicystitis or pyelo cystitis, urotropin is the 
remedy of choice. It acts best in combination with potassium citrate, 
5 grains of each every 4 hours. In refractory cases we may have to 



586 DISEASES OF CHILDREN 

resort to frequent irrigations of the bladder and even of the ureters. 
Chronic cases will often yield to these procedures alone or in conjunc- 
tion with biweekly hypodermic injections of autogenous vaccine. (See 
" Pyelitis''.) 

Vesical Calculi 

(Stones in the Bladder) 

Bladder stones sooner or later give rise to the following character- 
istic symptom complex : Vesical and often rectal tenesmus, strangury, 
partial or complete retention or incontinence of urine, difference in 
the force of the stream of urine with change in posture of the patient, 
and, after a protracted course, the usual symptoms of cystitis (q. v.). 
The urine may reveal the presence of either phosphate stones (phos- 
phate and carbonate of lime, magnesia), oxalate stones (oxalate of 
lime), or urate stones (uric acid). Small concrements may escape 
with the urine ; large ones, however, are apt to become impacted in 
the urinar}' canal and cause intense pain and grave nervous symp- 
toms, e. g., convulsions. 

The diagnosis is based upon the aforementioned manifestations, 
upon feeling the stone in the bladder by rectal digital examination or 
by a sound introduced into the bladder, and upon an x-ray examina- 
tion. 

The development of stones may frequently be prevented by a Jjland 
diet (no meats), ample supply of water, and attention to the bowels. 
In cases of long standing operative interference is indispensable. 
Painful symptoms are relieved by means of hyoscyamus, or opium and 
belladonna suppositories. 

Spasmus Vesicae, Dysuria, Ischuria 

(Anuria) 

These conditions are etiologically correlated. In the majority of 
instances they are the result of vesical calculi, blood clots obstructing 
the urinary flow, phimosis, paraphimosis, vulvitis and vaginitis, cys 
titis, uric acid infarcts (in the newborn), sudden chilling of and in- 
jury to the lower portion of the abdomen, nerve affections (functional 
or organic), and priapism (in the male). 

Treatment. — The treatment varies with the original cause. An at- 
tack is usually relieved by a hot bath, a suppository of codeine and 
extract of belladonna, and the administration of diuretics, such as 
sweet spirits of niter and extract, triticum repens. 



DISEASES OF THE KIDNEYS AND BLADDER 587 



Potassii Citratis 3 i 


4.00 


Ext. Hyoseyarni FL m. xvi 


1.00 


Ext. Tritici Kepens Fl. 5 i 


4.00 


Syr. Simplieis 3 iv 


15.00 


Aq. Anisi q. s. ad S ii 


60.00 


M. 




S. — One teaspoonful in water every three 


hours, for a child three years old. 




Enuresis 





(Bed-wetting. Incontinence of Urine.) 
It is customary to distinguish two varieties of enuresis in children : 
enuresis diurna and enuresis nocturna. The first variety is but rarely 
met with in children, capable of differentiating right from wrong, ex- 
cepting in those who willfully "wet" themselves, or in congenital 
deficiencies (spina bifida, q. v.). The second variety, on the other hand, 
occurs in a very great number of children, regardless of age, sex, in- 
telligence or social conditions. The child may wet the bed one or 
more times every night, or at intervals of days or weeks; in the last 
event, it is usually due to willfulness, excessive drinking, or faulty 
diet. An inherited tendency and neurotic disposition seem to play an 
important part in the causation of enuresis, although the latter may 
exist independently of either of these causes in children apparently 
perfectly healthy. 

The causes of enuresis may conveniently be arranged in two classes : 

1. Functional. — The cases due to functional causes are purely neu- 
rotic in character. The urine is voided involuntarily either owing to 
atony of the sphincter vesica?, or to a spasmodic condition of the detrusors 
vesicae. In both cases there is a functional disturbance in the nervous 
apparatus of the urinary system. It is usually found that enuresis due 
to atony is associated with general debility, and often follows a pro- 
tracted course of an exhausting disease. On the other hand, enuresis 
due to "spasm" is usually found in children who are irritable, who 
present an increased patellar reflex, are easily frightened, are subject 
to pavor nocturnus and similar nervous conditions. 

2. Organic. — A great many cases arise from organic troubles. 
The child may suffer from organic disease of the spinal cord (spina 
bifida); cystitis; phimosis or paraphimosis (in the male) ; hypertrophy 
of the clitoris or adhesion of the prepuce (in the female) ; masturba- 
tion; undescended testicle; hernia, worms; vesical and renal calculi; 
tumors in the bladder; excessive quantity of lithiates or phosphates; 
constipation and accumulation of feces in the rectum; epi- or hypo- 
spadias; fissura ani; vulvovaginitis; diabetes, gonorrhea, simple or 
gonorrheal proctitis. Finally it may here be mentioned that hyper- 



588 DISEASES OF CHILDREN 

tropliied tonsils and adenoids may be responsible for intractable enu- 
resis. 

Treatment. — In the treatment of enuresis it is of greatest moment 
to systematically examine the patients for the organic diseases just 
enumerated and to endeavor to eliminate every symptom suspicious 
of organic disease. In absence of organic causes there is evidently a 
neurotic case to be dealt with and the treatment must be adopted ac- 
cordingly. The patient if old enough should be instructed not to ab- 
stain from micturition when called upon by nature to do so, and small 
children should be trained to void urine every three hours, and not be 
permitted to withhold the urine for a longer period. This is very im- 
portant, for it is often overdistention of, and decomposition of the 
urine in, the bladder that prove the primary cause of the subsequent 
secondary etiologic factors, (atony or hyperesthesia of the bladder, 
presence of concretions, cystitis, etc.). It is also advisable to en- 
courage drinking of water in cases of enuresis due to concretions, 
cystitis, or gonorrhea, but to forbid it in other cases. The patient 
is not to be permitted to sleep on his back, and it is often of advantage 
to raise the foot of the bed in such a manner that the child's trunk 
and head lie deeper than the pelvis. 

In enuresis due to atony a general constructive treatment is indi- 
cated. Plenty of good nourishment, change of air, cold spinal douches, 
medicinal tonics and electricity are usually effective in bringing about 
a cure. A moderate galvanic current is usually best ; one pole is applied 
to the symphysis or sacrum, the other to the perineum. The following 
mixture is often very serviceable : 

Ijfc Ext. Ergotse Fl. 3 iii 12.00 

Ext. Ehus Toxicohdron 3i 4.00 

M. 

S. — Five to 10 drops every four to six hours, 
for a child six years old. 

In incontinence of urine associated with hyperesthesia of the collum 
vesicas or spasm of the detrusors, antispasmodic treatment is indi- 
cated, consisting of hot sitz-baths, avoidance of irritating food or drinks 
and the administration of either extract of belladonna or hyoscyamus. 
I usually prescribe the following : 
B 



Ext. Hyoscyami Fl. 3 ss 


2.00 


Natrii Bromidi 3 i 


4.00 


Syr. Simplicis 3 i 


30.00 


Aq. Anisi q. s. ad 3 ii 


60.00 


M. 




S. — One teaspoonful in water, three 


imes a 


day, for a child eight years old. 





DISEASES OF THE KIDNEYS AND BLADDER 589 

Counterirritation by means of sinapisms over the lumbosacral region 
often does well, and if everything fails, this class of cases is occasion- 
ally cured by gradual dilatation of the posterior urethral canal. 

More recently some benefit has been claimed from the administration 
of pituitrin, in 5 drop doses (placed under the tongue or hypodermic- 
ally) three times a day. 

As to the treatment of enuresis from organic causes, nothing more 
will be said here than that each case must be treated as an individual dis- 
ease in accordance with its etiology. 

Remonstrance, severity and moral suasion will often cure cases of 
enuresis of nervous origin or those which continue from mere habit 
long after removal of the original cause. 

Vulvovaginitis 

(Cervicitis) 

Clinically vulvovaginitis may be classified as follows: 

1. Catarrhal vulvovaginitis, which is generally due to (a) lack of 
cleanliness or (o) chemical irritation. 

2. Traumatic vulvovaginitis, which is due to (a) masturbation (?), 
(o) mechanical injury, or (c) indecent violence. 

3. Parasitic vulvovaginitis, which is due to (a) oxyurides, (Z>) 
saprophytes, or (c) pathogenic bacteria, especially the gonococcus. 

The first variety of vulvovaginitis is usually met in poorly nour- 
ished children of overcrowded tenement districts, who receive a thor- 
ough cleansing on very special occasions only. As a rule, these cases 
begin with vulvitis, the vagina becoming gradually involved by ex- 
tension of the inflammation. Catarrhal vulvovaginitis is not always 
limited to the very poor, and the physician need not hesitate to sus- 
pect dirt even under the most elaborate apparel. 

This variety of vulvovaginitis is also frequently observed in children 
whose genitalia are exposed to excessive wetting by irritating, de- 
composing secretions, and excretions — sweat, diarrheal stools, hyper- 
acid urine — and to undue pressure and friction. In former years, 
when bicycle riding was a national fad, vulvovaginitis was not rarely 
met with in assiduous bicycle riders, undoubtedly as a result of the 
aforesaid causes. To the catarrhal type belongs also the vaginitis 
occasionally observed in the newborn. 

The consideration of the second, traumatic, variety of vulvovagini- 
tis does not, strictly speaking, belong to the domain of medicine, 
except as regards the treatment. We are dealing here with faulty 
habits and criminal traits which deserve serious attention on the part 



590 DISEASES OF CHILDREN 

of teachers, the clergy, and jurists. However, as it is the physician 
who is usually consulted first, a few points of information will prove 
useful to him, particularly as a warning- not to be too hasty in ex- 
pressing a positive opinion. 

I believe that entirely too much stress is being laid by some authors 
upon masturbation as an etiologic factor of vulvovaginitis. It is much 
more probable that masturbation is a result rather than a cause of it, 
the undoubtedly existing irritated state of the erectile tissue inducing 
that bad habit. 

The presence of foreign bodies in the vagina is not infrequently 
found to be the cause of vulvovaginitis. While some girls will intro- 
duce foreign bodies in the vagina with lascivious intent, the great 
majority of foreign bodies, (e.g., safety pins), will find their way in 
the vaginal canal accidentally, and should always be looked for, par- 
ticularly in cases of long standing. 

Occasionally cases of vulvovaginitis are encountered which are the 
result of indecent violence. The purulent discharge is either non- 
gonorrheal or gonorrheal, the latter only if the criminal who at- 
tempted rape had at the time been suffering from gonorrhea. It is 
well to remember that not eA T ery case of vulvovaginitis reported as 
due to rape, is really such, and unless the vaginitis is associated with 
actual penetration of the hymen and concomitant signs of inflamma- 
tion due to violence, the physician should be very cautious in ventur- 
ing a positive opinion. 

Saprophytic microorganisms are responsible for a great number 
of cases of vaginitis. To them is attributable the vaginitis not in- 
frequently met with after acute exanthematous diseases (e. g., measles 
and scarlet fever) and in conjunction with divers forms of cutaneous 
eruptions. The same cause accounts also for the vaginitis observed 
in strumous and debilitated children suffering from purulent dis- 
charges from the nose, ears, etc. — the discharges being carried to 
the vagina. Indeed, the number of cases of saprophytic vulvo- 
vaginitis would by far exceed all those arising from all other sources 
collectively were it not for the antagonistic action of the bacillus of 
Doderlein which normally inhabits the vagina. This vagina bacillus, 
which is anaerobic and may be cultivated on ordinary media, produces 
lactic acid during its growth, a quality to which is due the presence 
of lactic acid in the healthy vagina. In its presence saprophytes, as 
well as numerous other bacteria, such as the staphylococcus and 
streptococcus, are unable to develop, and within a short time perish. 
Gonococci, however, do not yield as promptly to the destructive effect 
of the vagina bacillus; hence, the frequency with which gonorrheal 



DISEASES OF THE KIDNEYS AND BLADDER 591 

vulvovaginitis is met, notwithstanding the resistance offered to the 
entrance of gonococei into the vagina by the stratified squamous 
epithelium lining it. 

As stated before, contamination of the vagina by criminal assault 
is comparatively very rare. Much more frequently, infection takes 
place by voluntary sexual act or accidentally. Little girls sleeping 
with their parents, elder brothers, sisters, or nurses suffering from 
gonorrhea, may contract the disease by coming in contact with soiled 
bed clothes, cotton pads, or other articles used for cleansing purposes. 

Gonorrheal vulvovaginitis runs a more or less virulent course, and 
in hospitals and asylums where many children are congregated in 
comparatively close quarters, and frequently make common use of in- 
fected bath tubs, toilets, etc., the disease is very apt to become epi- 
demic as well as endemic. In one epidemic under my care in an 
orphan asylum, comprising over 100 cases, it required many months 
of very active treatment to eradicate the affection. Arrest of further 
spread of the gonorrhea was not effected until every patient was 
isolated and kept in bed for several weeks. A biweekly examination 
of every female inmate of the institution (including the nurses in 
charge) for vaginal discharge was continued for several weeks after 
disappearance of the last case of vaginitis. 

Such procedures form the main prophylactic measures against the 
disease. Of course, the patients must be restricted from the common 
use of chambers, bedding, bath tubs, etc. In hospitals and asylums, 
admitting physicians should be particularly careful to exclude all 
children having a purulent vaginal discharge, unless provision be 
made for the isolation and treatment of such cases. This point is well 
worthy of consideration, since it would greatly aid in checking further 
transportation of the disaese. As the majority of cases of vulvova- 
ginitis are observed among school children, a suggestion to the health 
authorities is, perhaps, in order, namely, to instruct the school inspec- 
tors to pay more attention to the detection and isolation of the cases 
of gonorrhea in children than they usually do. 

Like gonorrhea in adults, that of children presents a marked 
tendency toward grave complications. Among 148 cases under my 
care, the following serious complications were observed: purulent 
ophthalmia, 7; local peritonitis, 4; proctitis, 3; arthritis, 4; adenitis, 
12. Several cases of cervicitis,* endometritis and pyosalpinx; endo- 
carditis, and pleuritis are on record. However, the more familiar one 



*Hess reports that in 4 infants suffering from vaginitis he found (postmortem) an inflam- 
mation of the cervix with round-cell infiltration of its submucous tissue, and concludes that the 
average gonococcus infection involves the cervix rather than the vagina ("Gynoplastic Tech- 
nology," by Dr. A. Sturmdorf, 1919). 



592 DISEASES OF CHILDREN 

becomes with the course of the disease and the best means of check- 
ing and eradicating it, the less numerous will become the complica- 
tions and sequelae in his new cases. 

After extensive experimenting I found that gonorrheal oph- 
thalmia can best be prevented by frequent cleansing of the geni- 
talia and hands of the patients, and by the employment of a large, 
tightly fitting vulvar pad. The latter should be changed for a clean 
one at least every three hours. The child should wear one-piece night 
drawers during the night as well as during the day. The ophthalmia may 
sometimes be arrested in its incipiency — I succeeded in two cases — by in- 
stillation of silver solutions after Crede's method. In view of the 
unusually rapid progress of the ophthalmia, unfortunately, it is not 
often that the physician has the opportunity to resort to the pro- 
phylactic measures, and nothing else remains but to treat the disease 
actively and skillfully (see "Ophthalmia Neonatorum"), and, if not 
already involved, to endeavor to save the other eye from the dreadful 
infection. 

Involvement of the cervix and fundus of the uterus and adnexa, 
secondarily to gonorrheal vulvovaginitis, results in most instances 
from injudicious use of douches by forcing the vaginal discharge up- 
ward into the uterus, Fallopian tubes, etc. The treatment therefore 
should not be intrusted to the inexperienced. 

Many years ago I called attention (Amer. Medico-Surg. Bull., May 
30, 1896) to the occurrence of gonorrheal proctitis as a complication 
of vulvovaginitis. The rarity with which this complication is ob- 
served, notwithstanding the constant exposure of the anus to the 
gonorrheal vaginal discharge, would seem to prove the comparative 
immunity of the skin and mucous membrane of the anus and rectum 
to gonorrheal infection. Moreover, proctitis usually does not develop 
until late in the course of the vaginitis, i. e., until the skin of the anus 
and the adjacent structures have become abraded and denuded by the 
continued irritation of the vaginal discharge, or by scratching for the 
relief of the not infrequently accompanying intense itching. 

The diagnosis of gonorrheal proctitis is rendered positive by the 
presence of the gonococcus in the mucopurulent stools. 

Like the former complication, arthritis, the so-called gonorrheal 
rheumatism, also develops late in the course of vulvovaginitis. In the 
majority of cases the inflammation is limited to one joint, usually that 
of the knee, and occasionally ends in suppuration and ankylosis. 

Inguinal adenitis is quite a frequent complication. The glandular 
enlargement may increase up to a well-marked bubo. It sometimes 
suppurates as a result of an additional infection by pus microbes. 



DISEASES OF THE KIDNEYS AND BLADDER 593 

The differential diagnosis between the different varieties of vulvo- 
vaginitis can readily be made by bearing in mind the previously 
mentioned classification. No examination should be considered com- 
plete without a very careful microscopical scrutiny of the vaginal dis- 
charge. In doubtful cases a culture will settle the diagnosis. Fur- 
thermore, it is well to remember that several etiologic factors may 
be operative in the production of the vaginitis in one and the same 
patient. Hence, the finding of pinworms, for example, in the vagina 
should not lead us to conclude the absence of gonococci. 

The active treatment of vulvovaginitis varies greatly with the 
cause. Nongonorrheal cases usually yield promptly to removal of the 
etiologic factors (e. g., foreign bodies) and to cleansing of the genitalia 
with salt, boric acid, or 2 or 3 per cent permanganate of potash or 
sulphocarbolate of zinc solutions and daily sea salt sitz-baths. In some 
cases insufflations of tannic acid, in powder form, act very beneficially. 
Gonorrheal vulvovaginitis should be treated by instillation into the 
vagina (through a soft-rubber catheter) once a day or every other 
day of !/2 ounce of a 2 per cent to 5 per cent solution of nitrate of 
silver, followed by neutralization with salt water; or a 10 per cent 
solution of silvol, argyrol, or solargentum. After subsidence of the 
active symptoms douches with mild antiseptics will suffice. The sug- 
gestion recently made by a learned clinician to incise and dilate the 
hymen (in order to allow free application of antiseptics to the vaginal 
wall) is here mentioned only to be strongly condemned. 

Gonorrheal urethritis in male children is treated the same as in 
the adult. 

It is well to remember that recurrence of the affection after a period 
of latency is frequent even under the most careful method of treat- 
ment. No case of gonorrheal vulvovaginitis, therefore, should be 
considered cured unless three or more thorough microscopic examina- 
tions of the vaginal discharge prove the absence of gonococci and 
pus. 

Masturbation 

(Onanism, Thigh Friction) 

Production of venereal orgasm by hand, or other unnatural means, 
is a very common vice among school children, who usually acquire 
the vicious habit from older playmates, or erotic governesses, etc. 
Masturbation is quite common among mental defectives. 

Occasionally masturbation is observed in younger children and 
even in infants. The latter may be seen to rub their thighs against 
each other or against the bosom of the nurse, or to exert peculiar 



594 DISEASES OF CHILDREN 

rocking motions and fall back in a more or less marked state of ex- 
haustion. 

The effects of masturbation vary with the frequency and duration 
of the habit and the physical condition of the child. In the majority 
of cases masturbation produces physical and mental debility, espe- 
cially depression of spirit, headache, palpitation of the heart and 
emaciation. In boys we may suspect masturbation by excessive 
elongation of the penis, in girls by the presence of vulvitis, and often 
stretching of the hymen. Boys are apt to suffer from nocturnal 
seminal emission and later also from impotence. 

In remedying this evil, it is essential to remove all local sources 
of irritation, such as phimosis, hypertrophy of the clitoris, pinworms, 
etc. Infants should be restrained from practicing the bad habit by 
mechanical devices (separation of the thighs, tying of the hands). 
Older children should be placed under proper surveillance and in 
suitable spiritual surroundings (change of school or nurses!). The 
general health should be improved by outdoor exercise, cold shower 
baths, and by nutritious but bland diet (no liquors). Bromides are 
indicated to subdue sexual excitement. Dime novels should be elimi- 
nated from the child's reading room. 

Menstruatio Precox 

Genuine precocious menstruation in early childhood is of very rare 
occurrence. If it does occur, it is usually associated with general 
bodily and mental overdevelopment, most probably due to pituitary 
overactivity (see p. 571). The diagnosis of menstruatio precox should 
not be made until vaginal bleeding from local injury, from papil- 
lomatous growths, prolapse of the urethral mucous membrane, and 
hemophilia have been excluded. 

Precocious menstruation, being free from serious consequences to 
the general health, calls for no therapeutic measures, except perfect 
rest during menstruation. 

Gangrene of the Genitalia 

(Diphtheria Vulvae, Noma VuLViE) 

Gangrene of the genitalia (vulva, penis, scrotum, etc.) usually de- 
velops secondarily to grave local inflammatory processes in the vi- 
cinity. More rarely it is primary in nature (after too liberal use of 
strong antiseptic dressings in open wounds*, e. g., carbolic acid gan- 
grene in circumcision; the result of direct violence, e. g., stuprum), or 



DISEASES OF THE KIDNEYS AND BLADDER 595 

occurs in connection with diphtheria, dysentery, typhoid, and similar 
affections. 

Whatever the cause, the prognosis is always very serious, fatal ter- 
mination usually taking place within about ten days from the onset, 
unless we succeed in checking the spread of the gangrene by early 
cauterization or excision of the affected part. Diphtheria antitoxin 
is deserving of trial even if a smear or culture of the gangrenous de- 
posit proves negative. 



CHAPTER XII 

DISEASES OF THE NERVE SYSTEM* 

A. Organic Diseases 
Hydrocephalus, Congenital and Acquired 

(Acute and Chronic Dropsy of the Brain) 

Hydrocephalus is an accumulation of serous, slightly albuminous 
fluid within the cranium. It may be of prenatal origin or develop 
during or immediately after birth as a result of traumatism to the 




Fig. 169. — Congenital hydrocephalus. (Dr. M. Knowlton.) 

head; or it may make its appearance at any other time during infancy 
and childhood, either as a primary affection or secondarily to a num- 
ber of acute and chronic diseases. The fluid may collect in the sub- 
dural space (external hydrocephalus) or in the ventricles (internal 
hydrocephalus). The hydrocephalus may run an acute or chronic 



'For "Congenital Malformations," see p. 174. 

596 



DISEASES OF THE NERVE SYSTEM 



597 




Fig. 170. — Congenital hydrocephalus with spina bifida. Every few weeks the 
hernial sac would fill up with cerebrospinal fluid and rupture. A few days before its 
occurrence, there were distinct symptoms of brain pressure, including convulsions. 




Fig. 171. — Same ease as Fig. 170 showing distended spina bifida before escape of 

the spinal fluid. 

course. For detailed description of chronic, more particularly, con- 
genital hydrocephalus, the reader is referred to the chapter on ' ' Hydro- 
cephalic Amentia," p. 710. 



598 



DISEASES OF CHILDREN 



In order to obtain a clearer understanding of acute hydrocephalus, 
it is best to study its symptom complex in connection with the affec- 
tions which form its underlying pathologic basis, as follows: 

1. Meningitis Serosa (Acute Internal Hydrocephalus — Quincke). — 
This condition may complicate acute febrile diseases, such as pertussis, 
influenza, pneumonia or typhoid, or set in primarily in the same man- 
ner as serous effusions in other cavities of the body, e. g., pleuritis, 
pericarditis, and the like ; undoubtedly also as a result of bacterial 




Fig. 172. — Hydrocephalus following meningitis. 

invasion or traumatism. The quantity of fluid varies, and upon its 
amount and the pressure it exerts upon the surrounding structures 
depends the clinical course. If the pressure is great, we have sopor, 
spasms, strabismus and nystagmus, and the head may assume an 
enormous size. In infants, the fontanelles are bulging, the cranial 
sutures are separated, and the frontal bone protrudes markedly for- 
ward. In the early stages of serous meningitis there is moderate 



DISEASES OF THE NERVE SYSTEM 



599 



temperature. If recovery does not take place within a reasonable 
time the patient usually succumbs to gradual emaciation and increas- 
ing- cachexia. 

2. Tuberculosis of the Meninges or Brain. (Acute Internal Hydro- 
cephalus). — The hydrocephalus usually develops slowly. The infant may 
be affected with recurrent attacks of diarrhea, occasional vomiting, low 
fever, apathy, weakness of the extremities, and spells of sudden, 
piercing outcries, especially during the night. Older children often 
complain of severe headache, are languid and refuse to participate in 
the plays of their comrades. Gradually the symptoms grow worse. 
Vomiting, rigidity of the neck, and paralysis of the cranial nerves 
make their appearance, and, in a short time thereafter, the typical 
symptoms of cerebrospinal meningitis set in, which sooner or later 
lead to fatal termination. Ordinarily the hydrocephalus is not as 
marked as in meningitis serosa. 

3. Wasting Diseases, Acute and Chronic. — The hydrocephalus is 
usually slight, and hence does little or no damage to the brain. This 




Fig. 173. — Acquired acute hydro eephalus, following acute gastroenteritis and com- 
plicating rachitis. Note peculiar arching of forehead. 



is true especially of hydrocephalus accompanying rachitis, and acute 
and chronic gastroenteritis. With subsidence of the underlying cause 
the cranial distention generally disappears; the disfigurement of the 



600 DISEASES OF CHILDREN 

skull, however, may remain permanent. This form of hydrocephalus 
is sometimes spoken of as spurious. 

The symptomatology of chronic hydrocephalus, which occasionally 
follows serous meningitis is essentially identical with that of congeni- 
tal hydrocephalus, except that the tendency to idiocy is not as great ; 
indeed some of the children grow up with practically normal men- 
tality. Herein, of course, are not included the cases of hydrocephalus 
associated with cerebral tumors. 

The occasional concurrence of dyspituitarism and hydrocephalus has 
been emphasized by Harvey Cushing, 1 L. J. Pollock, 2 Frohlich, 3 Neu- 
rath, 4 Strauch, 5 by the author, 6 and others to whose instructive papers 
on the subject the reader is referred for further knowledge. 

Treatment. — The treatment varies with the etiologic basis of the 
affection. Lumbar puncture is always useful whenever pressure 
symptoms become evident, and in young infants we may also resort 
to puncture of the lateral ventricles. As hydrocephalus is sometimes 
a manifestation of congenital syphilis, specific treatment is worth 
trying, even though the Wassermann reaction may prove negative. 
For further information the reader is referred to the chapter on 
" Idiocy ".) 

Anemia of the Brain 

( Hydro ceph aloid ) 

This condition is usually the result of excessive loss of body fluids 
(repeated hemorrhages), general grave anemia, exhaustion from acute 
(rarely chronic), gastrointestinal diseases, interference with the blood 
supply of the brain (pressure on the part of tumors), etc. If the 
anemia is moderate, it is manifested principally by syncope. 

Anemia of the brain occuring in violent gastroenteric affections (with 
profuse vomiting and diarrhea) is generally spoken of as "kydroceph- 
aloid, ' ' so designated by Marshall Hall, who first described the symptom 
complex. Hydrocephaloid is characterized by a stage of excitation: 
flushed face, fever, restlessness, jactitations; and one of prostration: 
pallor, sunken face, irregular pulse and respiration, cold extremities, 
subnormal temperature, sunken fontanelles, stupor with half-closed 
eyes, hazy corneas, coma, convulsions, and, as a rule, death. 



1( "rhe Pituitary Body and its Disorders," 1911. 

hypopituitarism in Chronic Hydrocephalus, Jour. A. M. A, Jan. 30, 1915. 

3 Wien. klin. Rundschau, No. 45, 1901. 

4 Wien. klin. Wchnschr., No. 2, 1911. 

5 Jour. A. M. A., June 14, 1919. 

6 "The Backward Baby," p. 56. 



DISEASES OF THE NERVE SYSTEM 601 

Occasionally hydrocephaloid yields to energetic treatment, which con- 
sists of external heat, transfusion, stimulation 03^ entero- and hypo- 
dermoclysis, intravenous saline, sterile camphorated oil and strychnine 
hypodermically ; champagne and small quantities of food by mouth. 
Fresh air. 

The brain of infants dying from cerebral anemia is pale, watery and 
softer than normal. 

Hyperemia of the Brain 

The hyperemia may be active or arterial; passive or venous. 

Active hyperemia may occur as a result of sunstroke, traumatism, 
mental or physical overexertion, overstimulation by exhilarating bev- 
erages or drugs, hysteria, onset of acute infectious diseases, etc. 

It is manifested by deep redness of the face, congestion of the con- 
junctivas, contraction of the pupils, hot skin, high temperature, ac- 
celerated pulse, strong pulsation of the carotids and temporals, ring- 
ing in the ears, intense headache, excessive thirst, and in severe cases 
convulsions, dilirium, distention of the fontanelles, and other symp- 
toms of meningeal irritation. 

Passive hyperemia of the brain is caused by passive congestion of 
the cerebral veins owing to cardiac debility, grave pulmonary affec- 
tions (edema, pertussis, etc.), compression of the veins in the neck, 
etc. 

The symptoms of passive hyperemia are those of exhaustion, apathy, 
somnolence, cyanosis of the face and dyspnea. 

Treatment. — The treatment depends upon the original condition. 
It is more or less symptomatic — antiphlogosis in the active, stimula- 
tion in the passive variety of hyperemia. 

Upon the underlying cause also depends the final outcome. Pro- 
tracted hyperemia sooner or later leads to meningitis, rupture of cere- 
bral blood vessels, and dropsical effusion in the cranial cavities. 

General Remarks on Cerebral or Central Paralysis and 
Brain Localization 

"Cerebral paralysis," so-called, is not an independent brain dis- 
ease, but merely a symptom occurring in connection with a number 
of congenital and acquired brain affections. Depending upon the ex- 
tent of the lesion in the brain the paralysis may appear either in the 
form of hemiplegia, double hemiplegia, or monoplegia. 

Hemiplegia is the result of a lesion (disease or trauma) in one cere- 
bral hemisphere. The paralysis is situated on the side opposite that 



602 



DISEASES OF CHILDREN 
BRAIN LOCALIZATION 



Seat of Lesion 



Usual Manifestations and Their Seat 



Central convolutions : 

1. Upper third. 

2. Middle third. 

3. Lower third. 

(a) Upper part. 

(b) Lower part. 

Frontal convolutions. 
Parietal convolutions. 

Occipital convolutions (especially cu- 

iieus). 
Temporal convolutions. 

Centrum ovale. 

Central ganglia (caudate and lenticular 

nuclei). 
Optic thalamus. 
Internal capsule. 

Corpora quadrigemina (anterior pair). 

Crura cerebri. 

Pons and medulla (one-half). 



Cerebellum. 



Paralysis of leg, opposite side; convul- 
sions. 

Paralysis of arm, opposite side; convul- 
sions. 

Paralysis of the muscles of one-half of 

the face. 
Paralysis of the muscles of the lips and 

tongue. 
Disturbance of speech. 
Disturbance of cutaneous and muscular 

sensibility. 
Hemiopia; loss of visual memory. 

Disturbance of hearing, opposite side, 

and sense of smell. 
Monoplegia, hemiplegia, hemiopia, word 

deafness and aphasia: convulsions. 
Hemiplegia and hemianesthesia. 

Disturbance of vision up to blindness. 

Hemiplegia and hemianesthesia, and 
sometimes loss of special senses. 

Oculomotor paralysis, reeling gait, pos- 
sibly total blindness and deafness. 

Hemiplegia with cross paralysis of 
oculomotor nerve. 

Hemiplegia with cross paralysis of fa- 
cial nerve; hemianesthesia; also in- 
volvement of other cranial nerves, e. g., 
hypoglossal, abducens, varying with 
the height of the lesion. 

Ataxia, vertigo, and vomiting. 



of the lesion. Motile power may be completely abolished or only 
partially so (paresis). Sensation may remain intact, but is lost if 
the brain lesion is in the internal capsule and extends to the sensory 
fibers. The paralysis is associated with spastic rigidity of the affected 
muscles, exaggeration of the deep reflexes, implication of some of 
the cranial nerves, such as the facial (palsy of the lower part of the 
face), hypoglossal (deviation of the tip of the tongue to healthy side), 
and ocular nerves (nystagmus, hemianopsia, and optic atrophy), and 
occasionally, in a left-sided lesion, also with motor aphasia. As the 
paralysis becomes chronic the paretic musculature shows a tendency 



DISEASES OF THE NERVE SYSTEM 603 

to arrest of development, tremor and athetosis; and epilepsy and 
mental impairment up to total idiocy make their gradual appearance. 

Diplegia (double hemiplegia) may be the result of two separate at- 
tacks of hemiplegia. More frequently it develops with one attack 
as a sequel of extensive brain lesions in both cerebral hemispheres or 
in the pons and medulla (affecting both lateral halves). If only one 
side of the pons is involved, we have cross paralysis of the extrem- 
ities on one side and of the facial nerve on the other side. 

In double hemiplegia, in addition to the symptoms enumerated un- 
der hemiplegia, functions ma}' suffer which escape ordinary hemi- 
plegia, e. g., that of swallowing and, perhaps, that of micturition. Oc- 
casionally it is accompanied also by paralysis of the tongue, giving rise 
to symptoms which closely resemble those associated with bulbar 
paralysis. However, there is no wasting of the tongue, nor change 
in the electric reaction; hence, is spoken of as "pseudobulbar paraly- 
sis." 

Monoplegia as a primary manifestation of a cerebral paralysis is 
rare. More frequently it is met in the regressive stage of the afore- 
mentioned two types of paralysis or in connection with lesions of the 
spinal cord or peripheral nerves. Cerebral monoplegia usually arises 
from a limited lesion in or near the cortex (e. g., in simple encephalitis), 
less frequently from smaller capsular lesions involving individual 
nerve bundles for the face, arm, leg, etc. 

Intracranial Hemorrhage 
(Meningeal Hemorrhage, Hemorrhage in the Braix) 

We had occasion (p. 208) to direct attention to hemorrhages result- 
ing from obstetrical injuries. This space will be devoted to the dis- 
cussion of intracranial hemorrhages occuring during infancy and 
childhood. The usual sites for intracranial hemorrhages are as fol- 
lows : neighborhood of the large central ganglia, pons, meninges, 
convolutions, cerebellum, crura cerebri or medulla. 

They may occur as a result of trauma, such as a blow or fall upon 
the head; in association with meningitis, infectious diseases, purpura, 
pertussis (as a result of severe venous congestion) ; sinus thrombosis, 
syphilis (syphilitic arteritis), richly vascular tumors; nephritis and 
hypertrophy of the heart (owing to increased blood-pressure), etc. 

In the majority of instances the symptomatology is at first indefinite 
and inseparable from that of the fundamental disease. Where the 
hemorrhage is extensive, the symptom complex resembles in its en- 
tirety that observed in intracranial hemorrhage in adults. Thus : 



604 DISEASES OF CHILDREN 

unconsciousness, convulsions, slow, irregular breathing, slow and full 
pulse, coma and death, or partial recovery with persistent focal signs, 
especially paralysis (hemiplegia, diplegia or monoplegia). 

Treatment. — The treatment consists of an ice cap to the head, 
counterirritation (wet cups to nape of neck), perfect rest, light nutri- 
tious diet, and later, ergot and the iodides. In traumatic cerebral 
hemorrhage early operative interference is indicated. Pressure symp- 
toms may be relieved by lumbar puncture. 

Embolism of the Brain Arteries 

Cerebral embolism like hemorrhage is rarely observed in children. 
It is occasionally met in connection with severe valvular heart dis- 
ease, and acute infectious and pyemic processes, and most frequently 
affects the arteria fossae Sylvii. 

The symptomatology of embolism is practically the same as in cere- 
bral hemorrhage (q. v.), except that in the former the signs of cerebral 
compression and shock are not as persistent and as severe. Furthermore, 
the existence of valvular heart trouble decides in favor of embolism. The 
onset is usually sudden (occasionally preceded by headache, vomiting, 
etc.), with convulsions, coma, etc., followed either by early death, or 
partial recovery, with remaining focal symptoms, especially hemi- 
plegia and aphasia. In septic embolism there is irregular fever. 

Treatment. — The treatment is the same as in cerebral hemorrhage. 
Antisyphilitic treatment may be tried in cases of doubtful origin. 

Sinus Thrombosis 

Thrombosis in the large sinuses of the dura mater is most frequently 
observed in debilitated infants. Two forms are distinguished: pas- 
sive or marantic, being the result of retardation of the venous blood 
current in severe cardiac, gastrointestinal, or other exhausting dis- 
eases ; active or infective, occurring in connection with inflammatory 
processes in the vicinity, e. g., ear, nose, eyes, etc. 

Passive sinus thrombosis is usually limited to the longitudinal sinus 
and is manifested by symptoms of exhaustion and collapse and those 
of hydrocephaloid plus local edema and distention of the veins of 
the head and face. 

Active sinus tliromoosis usually involves the transverse and petro- 
sal sinuses and is characterized in addition to the aforementioned 
phenomena by more or less marked septic symptoms (vomiting, chills 
and fever, etc.), hemorrhagic infarcts and embolism, e. g., in the lungs, 
spleen and other organs of the body. 



DISEASES OF THE NERVE SYSTEM 605 

The differential diagnosis between the two varieties of sinus throm- 
bosis is quite difficult, but somewhat facilitated by lumbar puncture, 
which in the infective form reveals in the hemorrhagic cerebrospinal 
fluid numerous bacteria (strepto- or staphylo-, or pneumococci). When 
the longitudinal sinus is involved, there are epistaxis, cyanosis of the 
face, edema of the soft tissues of the frontal, parietal and temporal re- 
gions and frontal sweating. When the transverse and petrosal of one 
side are affected, corresponding collapse of the jugular vein and edema 
of the mastoid region result. When the cavernous sinus is implicated, 
exophthalmos, chemosis of the conjunctivae and lids are the distinctive 
signs. 

Treatment. — Where a diagnosis can be established early, opening 
of the sinus may prove a life-saving operation in septic sinus throm- 
bosis. Otherwise little can be accomplished in the way of therapy. 
In marantic sinus thrombosis, active stimulation may act well in some 
cases. The prognosis, thus being so extremely grave, our attention 
should be directed principally toward prophylaxis, especially as re- 
gards extension of the suppurative process from neighboring struc- 
tures. 

MENINGITIS ACUTA 

( MENINGITIS CEREBROSPINALIS) 

Meningococci^ Pneumococcic, Tuberculous, Streptococcic, Etc., Men- 
ingitis 1 

Meningitis may be primary or secondary in nature. Primary men- 
ingitis may be the result of traumatism (may involve both the dura 
mater — pachymeningitis hemorrhagica — and pia mater, but usually the 
former) or may be due to direct infection of the meninges by the diplo- 



1 Our venturesome attempt to disrupt the time-worn mode of grouping of the different 
varieties of meningitis is based upon the following considerations. 1. The symptom complex 
of fully established meningeal inflammation is practically identical in all forms of the disease, 
and differs only in the degree of mildness or severity of the attack, which depends upon the 
extent of the lesion, the susceptibility and the power of resistance of the patient to the microbic 
toxin and its baneful effects. 2. The same lack of distinction is observed in the pathologic 
anatomy of the divers forms of meningitis, except that in tuberculous meningitis we find in 
addition to the usual inflammatory process, local or general dissemination of tubercles, which, 
however, are not manifested by special clinical sumptoms. 3. Even the formerly accepted view 
as to 1he characteristic distribution of the inflammation in certain varieties of the affection, 
e. g., the so-called "vertical" or "basilar" meningitis, etc., is no longer scientifically tenable in 
a strict sense of the word, since meningitis of the convexity of today may, by extension, be- 
come that of the base the day following and vice versa. With these considerations in view, and 
appreciating also the fact that a positive differential diagnosis of the variety of meningitis 
can be made only by the findings of the etiologic factors in the cerebrospinal fluid obtained by 
lumbar puncture, we feel fully justified to discard the subdivision of meningitis into "serous," 
"purulent," "epidemic," "posterior-basic," etc., and to classify the disease from an etiologic 
point of view. Just as we speak of "tuberculous meningitis," we speak also of meningococcic, 
pneumococcic, streptococcic, influenzal meningitis, etc. — a classification which is not only 
scientifically correct, but at once offers a clue as to the etiology, mode of treatment, and 
prognosis. 



606 DISEASES OF CHILDREN 

coccus intracellularis meningitidis* (Weichselbaum, Leichtenstern and 
Jager) and other pathogenic bacteria, e. g., streptococci or staphylococci, 
and affect the pia mater of the brain as well as the cord — cerebrospinal 
meningitis. Secondary meningitis is due to extension of the infection 
from neighboring or more remote parts. This form includes the tuber- 
culous, or pneumococcus meningitis, as well as the meningitides which 
are met with in divers acute infectious diseases, such as influenza, ty- 
phoid fever, erysipelas, otitis, diphtheria and the like. The infection 
spreads either by continuity (throat, nose or ear), by the lymphatics, 
or by the blood vessels.! 

Meningitis is a disease peculiar to early childhood, the majority of 
cases occurring in the first three years of life. It prevails principally, 
often in epidemic form (epidemic cerebrospinal meningococcus or malig- 
nant meningitis) during the late winter and spring months, at a time 
when, with rapid changes in the weather and crowding of the children in 
stuffy rooms, "colds" and their sequelse are fiercely rampant. It is ob- 
served also sporadically during all seasons of the year. Delicate chil- 
dren are more prone to be attacked than robust ones, this being the 
case especially with tuberculous meningitis, which is frequently the cul- 
mination of latent tuberculosis of other organs of the body. 

The mode of onset of the disease varies greatly. It is usually abrupt 
in primary meningitis, rarely preceded by a few indefinite signs of ill 
health, such as anorexia, restlessness and headache. In secondary menin- 
gitis the attack, as a rule, develops more insidiously and is often obscured 
by the symptomatology of the preceding affection. Meningitis super- 
vening latent tuberculosis with few exceptions is particularly prone to 
be gradual in its development. In these cases the child may for weeks 
manifest apathy, anorexia, vomiting, wasting, occasional rise of tempera- 
ture, and other symptoms corresponding to the seat of the original lesion 
{e.g., caseation of the bronchial, mesenteric, or intestinal glands; bone 
or joint disease, etc.). 

Acute meningitis, be it primary or secondary, gives rise to dizziness, 
headache, nausea, projectile and usually persistent vomiting, rise of tem- 
perature, jactitations up to convulsions, alternating with drowsiness, 
stiffness and pain in the neck. This group of symptoms, while per se 
not at all characteristic, is nevertheless strongly suspicious of the dis- 
ease. Finding a patient in this condition we should at once carefully 



*Type A, P., C, or D. See p. 78. 

tBy special care in preparation of mediums and other details, Marshall A. Barber, Captain, 
S. C, N. A., and J. F. Fleming, First Lieutenant, M. R. C, have obtained positive blood 
cultures in twelve cases. Recent experience would indicate that with early diagnosis and 
proper laboratory technic the meningococcus may be grown from the blood in from 50 to 80 
per cent of all cases of epidemic meningococcus infection. W. W. Herrick: J. A. M. A., Aug. 
24, 1918. 



DISEASES OF THE NERVE SYSTEM 



607 



examine him for the following more or less pathognomonic physical 
signs and symptoms of meningitis: 

Opisthotonos or Rigidity of the Neck and Brudzinski's Sign. — This 
symptom is elicited by placing the hand under the patients' occiput 
and flexing the head upon the chest. In meningitis the neck will be 
found stiff and painful. Forcible flexion of the head upon the chest 
usually produces synchronous flexion of the legs upon the abdomen 
(Brudzinski's sign). The child instinctively assumes a lateral position, 
as the dorsal position proves very painful by pressure of the head 
against the pillow. Rigidity of the neck is present at one time or an- 
other in all cases of meningitis. It is especially pronounced in cases 
in which the inflammation begins at the posterior part of the brain. 
As the disease advances the rigidity extends to the muscles of the back 
and extremities, gives rise to a spasmodic rigidity of the body in which 
the trunk is arched forward and the shoulders and buttocks are thrown 
backward while the legs, as a rule, are flexed upon the thighs — opisthot- 




Fig. 174. — Epidemic cerebrospinal meningitis. (After Pfaimdler and Schlossmann.) 



onos. Occasionally the forearms are extended and the fingers clenched 
in the palm. 

Kernig's Sign. — This symptom consists of inability of the examiner 
to extend the patient's legs with the thighs flexed on the abdomen. 
It is met in the majority of cases of meningitis, but it is not entirely 
pathognomonic of the disease, since it is observed also in other af- 
fections, e. g., typhoid fever, and occasionally also in normal infants. 
In conjunction, however, with the other meningeal symptoms Kernig's 
sign is very helpful in the diagnosis. 

Babinski's Reflex. — Irritation of the plantar surface of a patient 
suffering from meningitis produces extension of the great toe with 
flexion of the other toes. It is a characteristic sign of disease 
of the pyrimidal and lateral tracts of the cord, hence is more apt to be 
observed in very diffuse forms of inflammation (tuberculosis) of the 
meninges and underlving structures than in the localized forms of the 



608 DISEASES OF CHILDREN 

disease. This sign is least reliable in infants under two years of age, 
but is of corroborative value in older children. 

Leichtenstem's Sign. — This consists of lightning-like contraction of 
the whole body on striking any part of the bony framework with 
the percussion hammer. It is a symptom of meningitis, principally dur- 
ing the stage of irritation. 

Reflexes. — In the early stages of meningitis the skin and tendon 
reflexes are somewhat exaggerated, but with the gradual loss of mus- 
cular power they disappear partially or wholly. 

Changes in the Eyes. — Intolerance to light and contraction of the 
pupils form early symptoms of meningitis. Dilatation or inequality 
of the pupils is usually met with later. The inequality is usually 
transient and variable, present at one time and absent at others : now 
one pupil, now the other may be the larger. Strabismus and nystag- 
mus are observed in advanced stages of the affection. Examination of 
the fundus reveals, in the majority of cases of tuberculous meningitis, 
optic neuritis or papillitis, and tubercles in the choroid. Optic 
neuritis is occasionally found also in other varieties of meningitis, 
chiefly when the base is involved. After the first week the child 
often keeps the eyes open staring immovably into distance. 

Vasomotor and Cutaneous Disturbances. — Cutaneous irritation is 
usually followed by a vivid and enduring congestion of the skin — 
taches cerebrates (Trousseau's sign). This symptom is not very signif- 
icant, being observed also in other infectious diseases, e. g., typhoid fe- 
ver. Eruptions of the skin — erythema, herpes, urticaria and purpura — 
are quite frequent. Purpuric spots are especially common in fulminant 
cases (hence often spoken of as spotted brain fever). They vary in 
size and may coalesce to form dark diffuse extravasations into the skin. 

McE wen's Sign. — With the patient in an upright position and his 
head inclined to one side, percussion over the junction of the lower 
portions of the frontal and parietal bones gives a tympanitic note. 
This situation corresponds to the anterior horn of the lateral ventricle, 
and the note is caused by the presence of fluid in the ventricle. Hence 
it is most frequently observed in the tuberculous variety of men- 
ingitis, where there is an accumulation of fluid in the ventricles. 
This sign is not pathognomonic before complete ossification of the 
skull. 

Mental State. — In the beginning of the disease the children are 
usually very irritable. They twitch, grind the teeth, start up with 
a cry of alarm when disturbed, are annoyed by the least sound 
in the room; but as the meningitis progresses, or in the tubercu- 



DISEASES OF TfiE NERVE SYSTEM 609 

lous variety often at its very inception, the patient gradually enters 
into a state of apathy, stupor and coma. 

Blood. — There is generally a high leucocytosis (as high as 45,000 
to 55,000 per cubic millimeter, rarely below 20,000) in the nontuber- 
culous forms. 

The experienced clinician, in order to arrive at a conclusion, rarely 
needs to wait for the synchronous inauguration of all of the afore- 
mentioned symptoms. Indeed, it is quite uncommon to meet with 
cases which present such an array of typical phenomena. One seldom 
errs in the diagnosis where persistent vomiting, convulsions, rigidity, 
photophobia and stupor are grouped together. However, the mere 
diagnosis of meningitis is not sufficient. It is also the cause and vari- 
ety we are interested in. 

Cerebrospinal Fluid. — With the latest improvements in the technic 
of examination of the cerebrospinal fluid obtained by lumbar punc- 
ture, numerous doubtful points of diagnosis can be cleared up which 
before the introduction of this diagnostic procedure forever remained 
a mystery. 

Normal cerebrospinal fluid is a clear neutral or slightly alkaline 
fluid, containing but a small proportion of salines, a small quantity 
(0.05 to 0.1 per cent) of serum globulin, a trace of cholin and a sugar- 
reducing agent (0.5 per cent). It is not spontaneously coagulable. Its 
specific gravity varies between 1,007 to 1,009. 

In normal individuals it escapes through the puncture needle at a 
low pressure, usually drop by drop. The pressure may accurately be 
measured by the manometer, but the experienced eye can well appre- 
ciate the amount of tension by observing the force of the jet. 

The pressure is usually increased in divers meningeal irritations and 
is particularly high in tuberculous and hydrocephalic conditions. As 
the stream may be altered by the position of the patient, by the viscosity 
of the fluid, by interference with the flow in its path etc., the semio- 
logic importance of pressure is rather slight. 

The color of the cerebrospinal fluid may be altered by accidental or 
pathologic admixture of blood, pus or pigment. In acute bacterial men- 
ingitis the discoloration varies from slight cloudiness to a well-defined 
purulent turbidity. In tuberculous miningitis the fluid is usually clear 
or slightly opalescent; on standing a thin film forms on the upper sur- 
face. The presence of blood is readily recognized and may be due to ac- 
cidental admixture from the puncture wound or to hemorrhagic pachy- 
meningitis. 



610 



DISEASES OF CHILDREN 



The bacteriologic examination of the cerebrospinal fluid is of inesti- 
mable clinical value, since it often furnishes reliable information not 
only as to early diagnosis, but to the prognosis and treatment as well. 
Too much stress cannot be laid upon the fact that, in order to obtain 
conclusive pathologic data, the examination of the fluid should be in- 
trusted to one thoroughly experienced in bacteriology and microscopy. 
Negative results in the majority of instances are due to skepticism and 
faulty technic. Occasionally repeated examinations are required. Nearly 
all kinds of microorganisms have been found. Careful search for the 




Fig. 175. — Lumbar puncture. The patient is put near the edge of a table in 
sitting or lying posture, with the vertebral column strongly arched forward. The 
puncture is made with a thin, hollow exploratory needle in the lumbar region, in the 
third or fourth intervertebral space, at a point corresponding to a line drawn between 
the superior crests of the ilia. 



tubercle bacillus should be made in all cases of meningitis, regardless of 
clinical data. The finding of the tubercle bacillus in the cerebrospinal 
fluid at a glance settles the diagnosis, where volumes of descriptions of 
differential features at best fail. The same applies for the diplococcus 
intracellularis meningitidis, and other pathogenic bacteria. 



DISEASES OF THE NERVE SYSTEM 



611 



CEREBROSPINAL FLUIDS 
(After Dr. A. Sophian) 





Normal 


Mcningism 


Poliomyelitis 
Polioenceph- 
alitis 


Cerebrospinal 
Meningitis 


Streptococcus, 

Pneumococcus, 

Influenza, etc., 

Meningitis 


Tuberculous 
Meningitis 


Color 


Clear 


Clear 


Clear 


Cloudy — pus 
sediment 


Cloudy- — pus 
sediment 


Clear — white 
flakes — fibrin- 
network 


Pressure 


Low — escapes 
slowly drop 
by drop 


+ 


+ 


+ + 


+ + 


+ + + 


Quantity 


Little — few 


+ (up to 50 


+ (up to 50 


+ + (up to 100 


+ + (up to 100 


+-H- (up to 100 




c.c. 


c.c. or more) 


c.c. or more) 


c.c. or more) 


c.c. or more) 


c.c. or more) 


Cytology 


Few cells, leu- 
kocytes and 
endothelial 


Few cellular 
elements 


Cells increas- 
ed (+) in 
number. Lym- 
phocytes 
90% or more 


Cells numerous 
+ + + (Polynu- 
clear up to 
100%) 


Cells numerous 
+ + + (Polynu- 
clear up to 
100%) 


Cells numerous 
++ (Lymph- 
ocytes up to 
90%) 


Bacteri- 


Sterile 


Sterile 


Sterile 


Meningococcus 


Infecting or- 


Tubercle bacil- 


ology 










ganism 


lus 


Albumin 


Faint trace 


Trace 


Trace 


+ + + 


+ + H- 


+ 


(nitric acid 
test) 














Fehling's 
Solution 


Reduces 


Reduces 


Reduces 


Unreliable 


Unreliable 


Unreliable 


Globulin 
Test 


Negative 


Negative 


Positive in 
early stages 


+ + + 


+ + + 


+ + 



For the detection of the microorganism we may use stained smears 
(the specimen having been obtained from the coagnlum that forms in 
the fluid on standing or after centrifugation), cultures, or inoculation 
methods. Where rapid decision is demanded the last two procedures are 
not adoptable, but as their scientific accuracy is incontestable they are 
not rarely indispensable in cases of obscure origin and especially in 
mixed infections. 

Cytodiagnosis. — This is based upon the histologic study and deter- 
mination of the number and nature of the formed elements in the cere 
brospinal fluid. Normally this fluid contains very few cells, so few 
that in a smear obtained from the deposit after centrifugation only 
two or three leucocytes may be visible in the microscopic field. The 
presence of leucocytes in great numbers constitutes anatomic evidence of 
a meningeal lesion — namely, of tuberculous nature, where lymphocytes* 
(mononuclears) prevail, and nontuberculous, where polymorphonuclear 
leucocytes predominate. This rule applies only to cases which are 
neither very recent nor very protracted, i. e., to the fully developed 
acute disease, since lymphocytosis is found in nontuberculous meningitis 
tending to recovery, in acute syphilitic meningitis, and in other chronic 



•See Encephalitis Lethargica, p. 624. 



612 



DISEASES OF CHILDREN 



brain affections, while polynucleosis is occasionally associated with 
lymphocytosis in chronic tuberculous meningitis. 

Of interest chemically are the facts that in meningitis the proportion 
of chlorides in the cerebrospinal fluid is often reduced while that of al- 
bumin is increased. The albumin consists principally of serin, while 
normally it is mostly globulin. The fibrin is increased, while the reduc- 
ing agent is often absent. 

The course of meningitis varies greatly not only with the cause but 
with the clinical types of the affection and the severity of the epidemic 
as well. Some cases are mild and transient, "abortive"; others are ex- 
tremely malignant, ' ' fulminant, ' ' in nature, ending fatally within a day 
or two, or sooner. The mode of commencement offers no certain indica- 



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spr a 


- &* 


S* 


*\ 


r$ 






















R 



Fig. 176. — Fever curve of tuberculous meningitis in a child two years old. 

tion as to the ultimate course. As previously mentioned, primary men- 
ingitis begins more suddenly and progresses more rapidly than the sec- 
ondary variety. The great majority of cases are usually ushered in by 
profuse vomiting, rise of temperature, severe headache, pain in the 
back and limbs, sensitiveness of the vertebral column, rigidity and con- 
vulsions. The fontanelles in infants are distended, the bowels confined, 
the abdomen retracted (trough-shaped), and the urine scanty, often al- 
buminous. During the early period symptoms of excitement of func- 
tion prevail. The patient is delirious, shrieks (hydrocephalic cry), is 
very sensitive to noises and light, but very soon he passes into a state of 



DISEASES OF THE NERVE SYSTEM 613 

sopor which gradually increases in intensity. At a later period of the 
disease there is depression of function. The pulse and respiration which 
in the beginning are accelerated, later become irregular and slow, the 
somnolence deepens to coma, and various paralyses appear. The afore- 
mentioned eye symptoms are usually quite marked and involvement of 
the facial nerve pronounced. In disease of the base, all parts of the 
facial nerve may be involved ; in that of the convexity, only the lower 
part may suffer. In hopeless cases deglutition also becomes affected; 
the coma increases, the patient can no longer be roused; the conjunc- 
tival reflex is abolished, the eyes are smeared with mucus or pus ; the 
cornea? are hazy or ulcerated: the sphincters are paralyzed; and after 
lingering in this moribund state for another few days the patient 
is finally relieved, of the agony by death. Milder, nontuberculous 
cases may gradually recover. In this event the disease is usually fol- 
lowed by very slow convalescence and frequently by deaf-mutism, 
aphasia, amaurosis, idiocy, etc. Meningitis sometimes runs a pro- 
tracted course, continuing for weeks with periods of marked im- 
provement, but finally ends fatally. These cases generally represent 
the chronic form of infantile meningitis, which is essentially a men- 
ingoencephalitis. 

Differential Diagnosis 

In the early stages meningitis may be confounded with typhoid fever, 
pneumonia, acute exanthematous diseases, uremia and eclampsia from 
other causes. In typhoid fever the vomiting is less persistent, diarrhea 
the rule, impairment of the sensorium less marked and more gradual in 
development, the spleen enlarged, the fever characteristic (step-curve), 
and the blood responding to "WidaL's reaction. Apex pneumonia partic- 
ularly may be mistaken for acute meningitis. In pneumonia the 
"cerebral" symptoms often clear up with the establishment of the signs 
of pulmonary consolidation or develop very late in the course of the dis- 
ease, the respiration ratio is increased and expiration is prolonged, and 
the temperature is evenly high. On the other hand, in meningitis, the 
nervous symptoms increase with time, respiration is irregular or ster- 
torous and inspiration prolonged and sighing, and the temperature va- 
riable. The differentiation between meningitis and a sudden attack of 
uremia is based principally upon the condition of the urine which 
should always be tested in case of doubt. The history also is very help- 
ful. Eclampsia caused by gastrointestinal intoxication, etc.. or develop- 
ing during the onset of some febrile disease is apt to be mistaken for 
meningitis the first twenty-four hours only — until the alimentary canal 



614 DISEASES OF CHILDREN 

lias been emptied, or the other causes of the eclampsia have become ap- 
parent. 

Latent tuberculous meningitis may lead to many errors in the diag- 
nosis. It may be confounded with severe remittent fever, encephalitis, 
syphilitic meningitis, and tumor of the brain. In remittent fever the 
Plasmodium malariae or pigment is readily found in the blood; encephal- 
itis can be excluded by the absence of tubercle bacillus in the cerebro- 
spinal fluid; in syphilitic meningitis there are other evidences of syphilis 
(choroiditis, rhagades, spirochete, etc.) ; in tumor of the brain the prog- 
ress of the disease is slow, and there are permanent focal symptoms 
(localized paralyses, optic neuritis, etc.) to account for a local lesion. 
In doubtful cases lumbar puncture and the tuberculin reactions will 
materially aid in the diagnosis. 

Bearing in mind the clinical signs and the findings in the cerebro- 
spinal fluid there should be but little difficulty in differentiating the 
usual forms of meningitis with fair precision — at least so far as it per- 
tains to the tuberculous or nontuberculous variety. Briefly stated the 
differential symptoms of the latter types are as follows: 

DIFFERENTIAL DIAGNOSIS 
Tuberculous Meningitis Nontuberculous Meningitis 

History: Preceding indisposition Apparent good health; infectious dis- 
eases or otitis 

Temperature: Low in the beginning High 

MacEweu 's sign : Pronounced Slight 

Cerebrospinal fluid : Clear ; tubercle Cloudy or purulent ; no tubercle- bacilli ; 

bacillus; lymphocytosis (mononu- polynucleosis 

clear) 

The eyes: Optic neuritis; choroid tu- Absent 

bercles 

Skin eruptions: Indefinite Frequently petechise 

Paresis: Early and variable Late 

Von Pirquet's test: Positive Negative 
Complement -fixation reaction : * Usually 

positive Negative 

The prognosis at best is very grave. Tuberculous meningitis is 
invariably fatal. The mortality in nontuberculous meningitis ranges 
between 50 per cent and 75 per cent. Where operative procedures can 
be brought into use, e. g., traumatic or otic meningitis with localized 
lesions, the outcome is more hopeful, provided no time is lost and the 
patient's general health is fair. 

Treatment. — Aside from operative treatment wherever indicated, 
lumbar puncture for the relief of pressure symptoms, and meningo- 
coccic antitoxin, little need be expected from all other methods of 

*See p. 84. 



DISEASES OF THE NERVE SYSTEM 615 

treatment in vogue. With the advance in onr bacteriologic study of 
the cerebrospinal fluid and the possibility of early detection of the 
etiologic factor of the meningitis in question, there is reason to hope 
that the majority of cases of meningitis will be combated by a curative 
serum. Wonderful results are already on record from the early intra- 
spinal and intravenous use of antimeningococcic serum in meningitis 
due to the diplococcus intracellularis. (See p. 78.) 

More recently some clinicians have claimed excellent results from 
the introduction of Flexner's serum directly into the lateral ventricle 
of the brain, after withdrawing the inflammatory exudate. This pro- 
cedure, of course, can only be employed in infants, where the ante- 
rior fontanelle is still open. (See p. 209.) 

The symptomatic treatment consists of warm baths with or with- 
out mustard every three or four hours; ice bag to the head, bro- 
mides and stronger hypnotics to relieve excessive irritation; small doses 
of calomel and large doses of sodium iodide; careful nursing (feed- 
ing by mouth, gavage* or per rectum), and stimulation as necessity 
arises. Special attention should be paid to cleanliness of the mouth 
and nasopharynx, and avoidance of decubitus. 

When an epidemic prevails, all such prophylactic measures should 
be instituted as are recommended for other contagious and infectious 
diseases, special care being taken to disinfect nasopharyngeal dis- 
charges. As a prophylactic urotropin also may be tried. 

3 Nairn Iodidi 3 ss 2.00 

Natrii Bromidi 3 i ss 6.00 

Aq. Mentha} Pip. 3 iv 15.00 

Aq. Destil. q. s. ad f I ii 60.00 
M. 

S. — One teaspoonful every six hours, for a child 

three years o]d. (Routine treatment.) 

I£ Hyosein. Hydrobromatis gr. y mo to gr. y B00 
S. — Hypodermically, for a child three to six years 

old. (To relieve excessive excitation.) 

Diplegia Spastica Infantilis 

(Congenital Eigidity of the Limbs, Little's Disease) 
The nature of this form of infantile paralysis is still obscure. De- 
generative changes have frequently been found in the pyramidal 
tracts or their correlated structures of the encephalon. But whether 
they are the results of early antenatal arrested development (poren- 
cephalia), intrauterine brain disease, traumatism during labor (embol- 

*By introducing through the nose a soft rubber catheter. 



616 



DISEASES OF CHILDREN 



isra or hemorrhage) by instruments or dystocia; or prematurity, are 
questions awaiting a correct solution. Some cases are certainly ac- 
quired. 

The symptomatology of this affection is sometimes manifested soon 
after birth and sometimes not until the child begins to walk. One of 




Fig. 177. — Diplegia spastica infantilis in a baby eight months old who sustained 
cerebral injuries (with hemorrhages) during obstetric delivery. Note rigidity of 
neck and extremities (right arm is contracted and right leg pressing against left 
one) : baby is unable to change its position without assistance. Note also convergent 
strabismus as a result of paralysis of the N. abducens. 




Fig. 178. — Little's disease. "Scissors-gait' 



or eross-i 



progression. 



DISEASES OF THE NERVE SYSTEM 



617 



the earliest symptoms is rigidity of the limbs. The child usually lies 
motionless (does not kick) with the legs pressed against each other 
or one upon the other. He begins to walk late and with difficulty or 
may not walk at all. If he is able to walk, he takes short, rigid steps 
with the feet in tiptoe position (talipes equinus) and the knees pressed 
closely together, or crossing each other, sometimes half running so 
that at every step a fall seems imminent. The rigidity gradually 
grows worse, leads to fixed deformities and extends to the upper ex- 
tremities and even the trunk. A Z-shaped deformity is often observed 
in the hand when the patient attempts to use it. Early in the disease 




Fig. 179. — Diplegia spastica infantilis (Little's Disease). Xote extreme spasticity 
of the muscles of the upper and lower extremities, and inability to stand erect with- 
out support. 



the deformities disappear during sound sleep or deep anesthesia. The 
knee jerks are exaggerated, ankle clonus is generally present, atrophy 
is slight and develops late, and the sphincters are normal. The major- 
ity of cases present symptoms of defective psychical development (up 
to idiocy), stammering, nystagmus, strabismus, athetosis and epileptic 
convulsions. Where the latter symptoms prevail, the prognosis is 
very bad, otherwise it is not absolutely unfavorable. 



C18 DISEASES OF CHILDREN 

Treatment. — Under suitable treatment the progress of the disease 
may be arrested and a partial cure effected. The treatment consists 
of stimulating baths, passive motion, educational exercises, massage 
and galvanization, and immobilization in the corrected position by 
suitable braces for a period of months. If this fails, we may resort 
to tenotomy, tenectomy, tendon transplantation, partial resection of 
the motor nerves (Stoffel's operation), and resection of the poste- 
rior nerve roots (Foerster's operation), followed by the aforemen- 
tioned therapeutic measures. Antisyphilitic medication is sometimes 
beneficial. When the seat of the lesion in the brain is discovered 
early, an attempt may be made to ameliorate the otherwise hopeless 
conditions by trephining, and evacuation of blood clots, — decompres- 
sion, — or removal of tumors, if there be any. Persistent and painstak- 
ing after-treatment is essential to success. (See p. 643.) 

The differential diagnosis between this disease and polioencephalitis 
is based principally upon the absence in Little's disease of true paraly- 
sis and the presence of the characteristic, jerky, half -running, spastic 
scissors-gait. 

Hemiplegia Spastica Infantilis 

(Spastic Cerebral Paralysis, Polioencephalitis Strumpell) 

The exact status of this diseased condition is still unsettled. Some 
authors look upon it as an irregular type of encephalitis (q. v.) or polio- 
encephalitis (see "Poliomyelitis"). 

Anatomically, after abatement of the acute process (which consists 
of inflammation, hemorrhage, embolism and thrombosis in the gray 
motor cortical substance) it is, manifested by sclerosis, atrophy, fatty 
or cystic degeneration of certain portions of the brain — of several 
convolutions, an entire lobe, or of the large brain ganglia ("agenesis 
corticalis"). Not rarely the pyramidal tracts down to the medulla 
spinalis exhibit secondary descending degeneration. 

It is a disease of early childhood, up to four years of age, and usually 
develops suddenly (very rarely insidiously), with fever, nausea, 
vomiting, headache and convulsions, or, less frequently in connection 
with other infectious diseases, such as exanthema, pneumonia, etc. 
After subsidence of the acute symptoms it is noticed that one-half of the 
body, or one arm or one leg is more or less paralyzed. The affected 
elbow hangs close to the body and the arm is bent to the ulnar side, 
while the fingers are flexed into the hollow of the hand; the foot is 
often distorted in an equinovarus position with the great toe overex- 
tended at right angles to the metatarsus. The patient walks practi- 



DISEASES OF THE NERVE SYSTEM 



619 



pally on the toes of the paralyzed leg. As the disease progresses, the 
affected limbs become atrophied and contracted and the hand manifests a 
great tendency to athetotic and choreic movements. The tendon reflexes 
are exaggerated and there is more or less marked muscular rigidity. 
The muscles never exhibit reaction of degeneration. Sensation is un- 
impaired. The cranial nerves (facial and optic), as a rule, are 
involved, but not to a great extent. Sometimes there are also dis- 
turbances of speech (as a result of involvement of the hypoglossus), 
epilepsy, and mental impairment up to total idiocy. In the course of 




Tig. 180.— Hemiplegia spastica infantilis, by some authors looked upon as a 
' ' cerebral ; ' or ' ' encephalitic ' ' type of poliomyelitis with lesions chiefly in the motor 
area of the cerebral cortex. Note peculiar position of the right leg in the act of 
walking and characteristic "athetotic" hand. 



time, especially under suitable treatment (which is practically the 
same as in anterior poliomyelitis) the paralysis, atrophy and contrac- 
tures may somewhat improve and, in mild cases, disappear entirely; 
but on the whole the prognosis is bad. The patients are usually help- 
less in mind and body, are very prone to suffer from epilepsy and, 



620 



DISEASES OF CHILDREN 



where the cerebral symptoms are pronounced, they rarely attain the 
age of twenty or thirty years. 

As alreacty suggested, this form of polioencephalitis may be mistaken 
for atypical encephalitis or anterior poliomyelitis. In both of these 
affections, especially in typical poliomyelitis, athetosis and spasticity 
of the extremities (both pathognomonic symptoms of spastic cerebral 
paralysis) are absent. Furthermore, in poliomyelitis there are reaction 
of degeneration and diminution or loss of tendon reflexes — the contrary 
being the case in the disease in question, This disease calls for further 
study for its clarification. 

The treatment is essentially the same as in encephalitis, q. v. 

Encephalitis 

(Nonsuppurative, Hemorrhagic, Encephalitis) 

Acute encephalitis is encountered principally in young children. It 
may be primary and occur either sporadically or in epidemic form, in 
the latter event often in connection with epidemic poliomyelitis. 




Fig. 181. — Left hemiplegia following acute encephalitis. Note drooping of left 
shoulder and dragging of left leg in the act of walking. 



DISEASES OF THE NERVE SYSTEM 621 

Secondary encephalitis usually occurs in association with divers 
acute infectious diseases, such as influenza, diphtheria, scarlatina, 
pneumonia, pertussis, etc. 

Any portion of the brain and medulla may be the seat of the in- 
flammation, although there seems to be a predilection for the gray 
substance of the cortex. The changes in the brain consist principally 
of cellular infiltration of the vascular walls, perivascular cellular 
exudation, hemorrhage and thrombosis. The larger foci at first ap- 
pear red and soft and later yellowish-white. After the process has 
run its course the affected part of the brain usually shows marked 
atrophy with cicatricial contraction. 

The clinical course varies with the seat and extent of the brain 
lesion. As a rule it begins suddenly with nausea, headache, vomiting, 
high fever and often convulsions. This is followed by stupor, slow 
pulse, Cheyne-Stokes' breathing, constant deviation of the eyes to one 
side ; and if the medulla is involved, also by implication of some cranial 
nerves, e. g., facial and hypoglossal. In infants the fontanelle is usually 
not bulging. As a rule the tendency of acute encephalitis is towards 
recovery, except for remaining mono- or hemiplegia, and often mental 
impairment (see Hemiplegia Spastica Infantilis, p. 618). 

Treatment. — The treatment is symptomatic. Ice bag to the head, 
warm baths, bromides and liquid nourishment. Lumbar puncture is 
of but little therapeutic value. 

Acute encephalitis may be mistaken for acute cerebrospinal or tu- 
berculous meningitis. The differential diagnosis must be based prin- 
cipally upon the cytologic findings in the cerebrospinal fluid (see 
p. 611). The absence of bulging of the fontanelles in infants points 
strongly against meningitis, more especially of the tuberculous variety. 
For its differentiation from polioencephalitis see pp. 620, 639. 

Brain Abscess 

(Encephalitis Purulenta) 

Suppurative encephalitis most frequently develops in connection 
with inflammatory or suppurative processes in adjacent structures, 
e. g., the eyes (panophthalmitis), the nose (caries of the cribriform 
bone), and especially the ears (mastoid disease). It also occurs as a 
result of traumatism, foreign bodies in the brain, pyemia, pulmonary 
abscess or gangrene, ulcerative endocarditis and embolism. 

The encephalitis may be diffuse or circumscribed, run an acute or 
chronic course. The classical brain abscess is the chronic variety. 
Pathologically, this term should be limited to circumscribed collec- 



622 DISEASES OF CHILDREN 

tions of pus in the brain surrounded by a yellowish-white, rather 
dense, newly formed membrane, possessing all the characteristics of 
a pyogenic membrane. It is not to be confused with an acute brain 
abscess in which definite lines of demarcation from the healthy tissue 
are absent. Congruent with circumscribed abscesses of other portions 
of the body, the inner layer of the membrane lining the pus cavity is 
formed of soft granulation tissue, while the contiguous structures 
are edematous, reddened and highly vascular. Brain abscesses may 
be single or multiple, and if multiple and of long duration may be- 
come confluent and attain considerable size. The pus in acute abscess 
is reddish or yellowish in color, while in chronic abscess the pus has 
a greenish-yellow color and a consistence similar to synovial fluid. 
It is acid in reaction. Unless contaminated by necrosis of the bone 
or foreign bodies the pus is usually odorless. An encapsulated ab- 
scess after remaining stationary for a considerable time shows a tend- 
ency to extend, not gradually, but in steps. According to Bergmann, 
each step represents a new inflammation, and at autopsy one finds 
the traces of a recent softening adjacent to some portion of an older 
abscess cavity. Large portions of the brain may thus be destroyed, 
and if the gray matter is preserved, an abscess may extend over the 
whole lobe or even throughout an entire hemisphere without produc- 
ing definite symptoms indicating the trouble. The meninges rarely 
escape involvement. 

The clinical picture of purulent encephalitis is very misleading and 
varies greatly with the seat and extent of the lesion and the stage of 
the disease. It is less confusing in cases of cranial traumatism, but, 
even in as severe an injury as fracture of the skull, the cerebral symp- 
toms may be so vague as for days to escape notice. The onset is 
usually sudden with nausea, vomiting, fever, stupor, and convulsions. 
Older children complain of dizziness and headache. This condition 
may last one or two days or as mairy weeks. Then either the coma 
increases and is followed by death, or the symptoms abate, and the 
patient is apparently on the road to recovery, except that in the 
majority of instances monoplegia, or hemiplegia with or without in- 
volvement of some cranial nerves is left behind. The subsequent 
course of the disease depends upon the nature of the brain lesion. 

Suppurative encephalitis of very limited extent, with its cause re- 
moved, may clear up without appreciable after effects. On the other 
hand, where an encapsulated abscess has formed, the violent symptoms 
may abate and the acute pass into a chronic stage. This state reached, 
the encephalitis is apt to run a very protracted course; with recurrent 
violent exacerbations and deceptive remissions; on the one hand, giv- 



DISEASES OF THE NERVE SYSTEM 623 

ing rise to symptoms of acute meningitis; on the other, especially if 
the abscess is large and pressing upon the motor areas and cranial 
nerves, to those of tumor of the brain. In either case the diagnosis 
is often extremely difficult. Ordinarily meningitis differs from abscess 
in that it pursues a more acute course, and the brain symptoms are in- 
dicative of a more diffuse lesion. The diagnosis between brain tumor 
and abscess is much more difficult. In abscess there is usually an ir- 
regular temperature with rigors, motor aphasia and paraphasia, while 
in tumor fever is rare and there is a greater tendency toward disturb- 
ances in the area of distribution of the cranial nerves at the base of the 
brain, and toward choked disc. (See " Brain Tumor", p. 645.) A 
history of ear disease or direct violence points strongly toward abscess. 
Slowly developing focal brain symptoms are characteristic of brain 
tumor. These differential points, however, at best, are not very reli- 
able. 

As previously mentioned, the remissions occurring during the course 
of chronic brain abscess are very deceptive. In the first place, the 
" latent period" is rarely entirely free from signs of ill health. As 
a rule, the patient suffers from occasional headache, vomiting, rise of 
temperature, mild paresis, etc. Secondly, there is no way of telling 
when in the midst of apparent good health the abscess may suddenly 
rupture in the brain ventricles or meninges and rapidly end fatally. 

Treatment. — The prognosis of brain abscess, therefore, is always very 
grave, unless surgical interference is resorted to early. The operative 
results are especially favorable in abscesses due to otitis or trauma — 
provided they can be localized. 

Purulent encephalitis before operation, should be treated by perfect 
rest, ice bags to the head, lumbar puncture, etc. — the same as acute 
meningitis. 

Early prophylactic measures, especially energetic treatment of ear 
trouble, scrupulous attention to suppurative conditions of the eyes, 
nose and throat are all powerful in the prevention of the dreadful 
complication and sequela?. 

To emphasize the difficulty encountered in diagnosing chronic brain 
abscess even under the most modern methods of observation, I may re- 
late the following interesting case : 

H. D., aged four years, 27 lbs. in weight. Family history good. Parents living 
and well, have four additional healthy children. Child was normal at birth, breast 
fed, and free from any serious illness until two years of age, when he had an attack 
of measles, apparently mild in character. One year later he began to complain of 
headache and occasional vomiting. This condition continued for several months, 
notwithstanding careful care and treatment, and a stay at Mt. Sinai Hospital for 



624 DISEASES OF CHILDREN 

ten days. He came under our observation at -the end of November. We made a 
tentative diagnosis of tuberculous meningitis. Admitted to the Postgraduate Hos- 
pital (H. D. Chapin's service) December 1st. Temperature for following week ranged 
between normal and half a degree above, pulse between 70 and 92, and respiration be- 
tween 24 and 28 per minute. Child moaned and complained of headache. Persistent 
projectile vomiting, especially after breakfast. Staggering gait, ataxia of right arm. 
Choked disc in both eyes, more marked in left. Tuberculin and Wassermann reactions 
negative. The same result of examination of cerebrospinal fluid and urine. Blood 
shows 90 per cent hemoglobin, 5,392,000 erythrocytes, 24,000 leucocytes, 36 per cent 
lymphocytes and 64 per cent neutrophiles. Roentgen-ray examination discloses the fol- 
lowing picture: Pituitary fossa enlarged and base eroded; glenoid processes atro- 
phied; also atrophy of anterior portion of vault — -all pointing to tumor of pituitary 
gland. Operation, January 5. Escape of large quantity of cloudy fluid, free from 
tubercle bacilli. No growth about cerebellum and nothing found after incision in 
right lobe. An ulcerated spot about y 2 inch in diameter is visible on superior sur- 
face of vermis. Puncture of this area fails to bring pus. The boy promptly recov- 
ered from the effects of the operation and improved for about ten days. Gradually 
grew worse thereafter; developed a higher temperature, from 101° to 105° F. and 
died January 27. Autopsy: Large ulcerated area, size of silver dollar, in summit 
of vermis, purulent collection under the membrane about pons and crura. Incision 
of cerebellum reveals an abscess cavity size of thumb and almost 1% inches in 
length, occupying the right lobe and extending slightly to the left lobe. Pus shows 
no bacteria in pure culture. 

Whether the abscess was the direct result of the measles or the consecutive 
latent otitis could not be determined. 

Lethargic or Epidemic Encephalitis 

(Meningo, Encephalo-, Myeloneuritis) 

Though supposedly of very recent origin, this affection has undoubt- 
edly occurred on previous occasions, and either passed unnoticed 
or was diagnosed as nonsuppurative encephalitis or the cerebral type 
of poliomyelitis, with both of which diseases it has several symptoms in 
common. There are two definite records which substantiate this view. 
An epidemic of "sleeping sickness" occurred in 1712 in Tubingen 
(Germany) and its vicinity. The other record refers to an epidemic 
of encephalitis which prevailed in 1890 during and after the influenza 
epidemic in Austria-Hungary, Italy and Switzerland, and was then 
spoken of as "Nona." The most recent epidemic of lethargic encephali- 
tis dates back to 1916, and was first described by von Economo of Vienna. 
Since then numerous cases have appeared in divers parts of Europe 
and America, following the trail blazed by the destructive epidemics 
of influenza, justifying the assumption either that this affection acts 
as a predisposing cause of encephalitis, or that the same infectious 
agent forms the etiologic factor in both affections. Von "Wiesner, 1 



a Wien. klin. Wchnschr., p. 933, 1917. 



DISEASES OF THE NERVE SYSTEM 625 

J. A. Wilson, 2 and Strauss "and Loewe 3 present evidence to the 
contrary, yet, until further preponderating corroboration has been 
adduced, the question of the exact identity of the causal factor is best 
left in abeyance. 

Pathology. — Whatever its identity, recent observations have shed 
considerable light on the mode of activity of the infectious agent. It 
has been shown to attack the central and peripheral nervous system 
and its coverings in a very widespread manner. The structures par- 
ticularly involved are those about the third ventricle, the acqueduct 
of Sylvius, the lateral ventricles and optic thalamus, and the pons and 
medulla. Occasionally lesions are found also in the cortex and in the 
cerebellum. The spinal cord also is subject to attack. The lesions are 
of an inflammatory, sometimes hemorrhagic, character, and occur in 
nodular and diffuse forms. 

Microscopically we find thickening of the leptomeninges with exu- 
dation or vascular congestion. The gray matter is the site of peri- 
vascular cellular infiltration. There is ample evidence of toxic de- 
generation of the nerve cells and neuronophagy. 

Symptomatology. — The symptoms correspond, of course, with the 
functions of the cerebrospinal system affected. Thus, if the lesion is 
localized in the globus pallidus, tremor and rigidity result; if in the 
thalamus : choreiform athetotic movements ; if in the meninges : rigidity ; 
if in the spinal cord : neuritic pain ; if in the cranial nerve nuclei : facial 
paralysis, ophthalmoplegia, etc. ; and finally if the cerebellum is attacked, 
ataxia supervenes. In our opinion it is erroneous to speak of special 
types of the disease, as the symptomatology may at any moment 
undergo considerable modification with extension or retrogression of 
the inflammatory process. 

In children the onset of the affection is rather sudden, with rise of 
temperature, vomiting and more rarely, convulsions. Sometimes the 
attack is preceded by sore throat, lassitude, and headache. The fever 
usually remains moderate during the entire course of the disease, only 
exceptionally reaching 104° or 105° F. The pulse is generally rapid, 
and, as will be mentioned later, may become very irregular. About 
twenty-four hours after the onset it is noticed that the patient is 
losing interest in his surroundings, becomes drowsy and apathetic, 
and, as time goes on, the lethargy becomes so deep and continuous as 
almost to resemble a state of coma. Yet with some effort the patient 
may be sufficiently aroused to respond to questions and to partake 
of nourishment. During the profound lethargy the child's face as- 

2 Ouart. Jour. Med., Oxford, p. 88, 1918. 
3 jour. A. M. A., p. 1373, 1920. 



626 DISEASES OF CHILDREN 

suines a mask-like appearance (Parkinsonian); it is pasty, waxy and 
motionless. Some children are disturbed in their slumber by sharp 
pain in the face, arms and legs, and when aroused present marked choreic 
or athetotic movements of the head and arms. In the great majority of 
cases there is more or less pronounced involvement of the cranial 
nerves. Most common by far is oculomotor and abducens paralysis, 
with ptosis, diplopia and ophthalmoplegia externa and interna. Next 
in frequency is unilateral or bilateral facial paralysis. More rarely, 
the glossopharyngeal and vagus are affected, as may readily be deter- 
mined by the impairment in speech and difficult deglutition, respira- 
tory and cardiac arrhythmia, hiccough, etc. In a number of cases, 
and usually late in the course of the disease, rigidity of the neck, 
Kernig's and Brudzinski's signs are present, and where the motor 
areas are involved, monoplegia, hemiplegia and diplegia supervene. 
Occasionally, also, anesthesias and paresthesias and spontaneous muscle 
spasms are encountered. 

Diagnosis. — In view of the multiplicity of the symptomatology the 
diagnosis, in the absence of an epidemic, presents considerable diffi- 
culty. Lethargic encephalitis may be mistaken for nonsuppurative 
encephalitis (see p. 620), complicating or following divers acute in- 
fectious diseases; cerebrospinal meningitis, tuberculous meningitis 
and polioencephalitis. Lethargic encephalitis is characterized by 
progressive stupor, early involvement of the cranial nerves, espe- 
cially the oculomotor (ptosis, etc.) ; paralysis of the extremities, late 
if at all; mask-like face; neuritic pain and choreiform movements or 
tremors. In simple encephalitis the cranial nerves are affected late, 
whereas mono- or hemiplegia appears early ; the Parkinsonian expression 
of the face, the choreic movements and pain are usually absent. In 
cerebrospinal meningitis opisthotonos, Kernig's and Brudzinski's 
signs appear early and are very marked, and there are several other 
symptoms in meningitis which are absent in lethargic encephalitis. 
In tuberculous meningitis, the onset is usually slow, paralysis and 
optic neuritis occur early; Babinski's reflex and McEwen's sign are 
marked, tubercle bacilli are present in the cerebrospinal fluid and 
there are in addition other symptoms of acute meningitis. In polio- 
encephalitis paralysis of the extremities appears early, while the 
mask-like face and profound stupor are absent. According to Barker, 
Cross and Irwin,* a cell count in the cerebrospinal fluid of from 10 to 
100 small mononuclears along with a positive globulin reaction, a 
negative AYassermann and absence of tubercle bacilli or meningococci, 



*Am. Jour. Med. Sc, March, 1920. 



DISEASES OF THE NERVE SYSTEM 627 

at a time of an epidemic of encephalitis, point strongly to the ex- 
istence of this disease. 

Prognosis. — As a rule, the course of the disease is protracted, ex- 
tending over many weeks, although occasionally mild as well as se- 
vere cases are encoutered which are on the road to recovery in a few 
days. On the other hand, fulminant cases of epidemic encephalitis 
are met with which may end fatally in but a few hours. The death 
rate is lower in children than in adults, and ranges between 10 to 
20 per cent. Involvement of the sphincters, hyperpyrexia and pro- 
gressive stupor are of grave import ! 

Convalescence is usually slow and occasionally interrupted by 
slight relapses. The possibility of sequelae in the form of mental 
deterioration and epilepsy, should not be lost sight of. 

Treatment. — Absolute rest to body and mind is essential during 
the entire course of the disease. Liquid diet; where deglutition is 
difficult milk and broths may be given by gavage, with a catheter 
introduced through the nose. This may be repeated twice or thrice 
daily. In the early stages I believe to have obtained great benefit 
from wet cups applied to the nape of the neck. From 4 to 6 ounces 
of blood is withdrawn once or twice. The temperature and pain are 
best relieved by warm baths, with or without mustard. In symptoms 
of brain pressure, especially where several cranial nerves are involved, 
lumbar puncture is quite useful. Netter* recommends the induction 
of a fixation-abscess by a subcutaneous injection of 1 c.c. of turpentine. 
Hexamethylenamine is worth trying, especially in the early stages of the 
disease. 

During convalescence prolonged rest and quiet preferably in the 
country. Nutritious diet. Massage and hydrotherapy. Hematinic 
tonics. 

Poliomyelitis Anterior 

(Polioencephalitis, Poliomyeloencephalitis, Infantile Paralysis) 
(Heine-Medin Disease) 

Our knowledge of poliomyelitis has been slow and gradual in its 
evolution notwithstanding the fact that two score or more epidemics f 
of the disease have offered unusual facilities for its careful study. 



*Bull. de 1' Academie de Med., Vol. 83, No. 13, 1920. 

fin modern times the following great epidemics of poliomyelitis have been recorded. In 
1905, in Norway and Sweden, together 2000 cases. In 1907 the first great epidemic occurred 
in America, 2500 cases being reported in and around New York. In 1909 there were out- 
breaks in various parts of the United States and Cuba with a total of 2,343 cases. In 1910 
an epidemic of infantile paralysis spread almost throughout the entire country, about 500 
cases occurring in the District of Columbia, Iowa, Massachusetts, Minnesota, Indiana, and 
Pennsylvania, and about 400 cases in Maryland, New Hampshire, New York, Rhode Island, 



628 DISEASES OP CHILDREN 

The first scientific essay on the subject was written by J. Heine in 
1840. Herein he attributes the affection to a lesion in the spinal cord. 
In 1851 Killiez and Barthez contested this view and designated the 
disease as "Essential Paralysis of Children." In another contribu- 
tion on the subject, in 1860, Heine reasserted his opinion, but failed 
to meet with authoritative support, until, in 1870, Joffroy and Charcot 
announced that they found distinct changes in the spinal cord con- 
sisting of "primary involvement of the ganglion cells leading to atro- 
phy." Thereupon "Essential Paralysis" was replaced by "Spinal 
Paralysis in Children," or, in short "Infantile Paralysis." In 1872 
Duchenne called attention to the loss of reaction in the paralyzed 
muscles to the faradic current, and four years later Erb demonstrated 
absence of reaction also to the galvanic current. Our knowledge was 
further advanced by Seeligmuller by furnishing an instructive con- 
tribution to the study of the pathogenesis of the contractures and 
deformities following poliomyelitis. All the while every trifling ail- 
ment and mishap were blamed for the origin of the disease in ques- 
tion; and although in 1884 Striimpell suggested that an infectious 
agent must play an active role in the causation of the affection, we 
still note that as late as the year 1893 no less an authority than 
Gowers relates several cases of poliomyelitis which he thought were 
due to catching cold from sitting on wet grass. Medin is deserving 
the credit for having systematized the symptomatology of infantile 
paralysis — in 1890 — and we are indebted to Wickman for developing 
— in 1907 — the epidemiology of the disease and for classifying it into 
several distinct types. Our knowledge of the etiology of poliomye- 
litis was greatly enhanced — in 1909 — by Landsteiner, Popper, Flex- 
ner and Lewis, who demonstrated experimentally that monkeys are 



Virginia, Washington and Wisconsin. The epidemic of 1916 exceeded all previous epidemics 
in severity as well as in the number of cases, in New York State alone over 13,000 cases hav- 
ing been reported. The total must assuredly have been much larger, since a great many mild 
and so-called abortive cases must inevitably have escaped attention. A large number of cases 
have recently reappeared in Boston and vicinity and about 100 cases in New York. 
POLIOMYELITIS IN BOSTON 





Total 


Total 


Non-resident 


Resident 


Massachusetts 


Week Ending 


Cases 


Deaths 


Cases 


Deaths 


Cases 


Deaths 


Cases 


July 24, 1920 


1 


1 





1 


1 





4 


July 31, 1920 


8 





2 





6 





10 


August 7, 1920 


5 


2 








5 


2 


5 


August 14, 1920 


15 


4 


2 


1 


13 


3 


16 


August 21, 1920 


13 


3 


6 


1 


7 


2 


25 


August 28, 1920 


14 


3 


3 





11 


3 


26 


September 4, 1920 


22 


9 


7 


3 


.15 


6 


52 


September 11, 1920 


26 


3 


13 


2 


13 


1 


53 


September 18, 1920 


29 


4 


9 


2 


20 


2 


66 


September 25, 1920 


30 


4 


10 


3 


20 


1 


68 


October 2, 1920 


27 


3 


12 


2 


15 


1 


72 


October 9, 1920 


11 


1 


1 





10 


1 


53 


October 16, 1920 


11 


3 


3 


1 


8 


2 


46 



Totals 212 40 68 16 144 24 496 



DISEASES OF THE NERVE SYSTEM 629 

susceptible to this affection, and, furthermore, that in these animals 
one attack of paralysis prevents a second successful inoculation; in 
other words, it produces an immunity against the disease. Further 
studies, moreover, established the fact that in human beings also one 
attack immunizes against another one, and that the serum of recov- 
ered monkeys as well as men contains a specific substance which is 
capable of neutralizing the virus in vitro. This neutralizing agent 
was shown to exist also in the blood of a large number of so-called 
abortive cases. 

Etiology. — With these facts in view an entirely new light was 
thrown upon the mode of dissemination of the disease, since it be- 
came immediately obvious that poliomyelitis, like so many other com- 
municable affections, is transmitted by an infective agent that follows 
the lines of human contact and travel, and is carried not only by the 
victims of the disease, but by virus-carriers as well. Experimental 
and clinical evidence is gradually accumulating which tends to show 
that the virus of poliomyelitis enters the human body most frequently, 
even if not exclusively, through the upper respiratory tract and is 
carried to the cerebrospinal system by means of the lymphatics. 

Owing to the not infrequent occurrence of paralysis among lower 
animals, e. g., chickens and dogs ("distemper"), some authors thought 
it plausible to fasten the source of infection to this agency, but careful 
investigations undertaken during the 1916 epidemic by the Federal and 
States Boards of Health, with the assistance of expert veterinarians, ut- 
terly failed to substantiate that assumption. Moreover, it was con- 
clusively shown that in fowl, for example, the paralysis was the result 
of peripheral rather than central nerve lesions. There is much more 
scientific basis for the supposition that the disease may be conveyed by 
flies, since it has been repeatedly demonstrated by Flexner and Clark 
among others that the common house fly can carry the virus of poliomye- 
litis in a living and actively infectious state for forty-eight hours or 
longer, and abounds during the period of greatest prevalence of the dis- 
ease, i. e., the hot summer months. Now, if we accept the hypothesis of 
transmission of poliomyelitis by insects, more especially flies, then the 
probability of conveyance of the disease to the human body by means 
of food contaminated by house flies and the like holds true with equal 
force. Be it remembered, the virus of poliomyelitis withstands both 
low degrees of cold as well as ordinary degrees of heat for long periods 
of time, and when enclosed in albuminous matter it resists drying for 
several weeks. In view of the aforesaid and the fact that the greatest 
number of victims of the affection are met in children under three years 



630 DISEASES OF CHILDREN 

of age* whose diet consists principally of milk, this article of food must 
naturally come under the suspicion of being the purveyor of the in- 
fectious agent of poliomyelitis. Yet, after a very thorough investigation 
of the subject in question, the Committee of the Department of Health 
of the City of New York has arrived at the conclusion that food, and 
milk in particular, plays no part in the transmission of the disease. 
We must add, however, that this exhaustive investigation notwith- 
standing, we would err greatly in ignoring the aforementioned hy- 
pothesis so far as prophylaxis is concerned, at least until such time 
as the identity of the infectious agent is definitely established. Un- 
fortunately thus far all bacteriologic researches have failed to 
demonstrate the etiologic factor of poliomyelitis microscopically. It 
is therefore generally assumed that it is not bacterial in character, 
but belongs to the group of the so-called ultramicroscopic filtrable 
viruses. Experimentally it has been shown to be highly resistant to 
diverse destructive measures. It withstands glycerination for long 
periods of time and is not affected by 0.5 per cent of carbolic acid; 
it is but slightly influenced by freezing at 2 to -4° C. for forty days ; 
the virus is less resistant to high degrees of heat — it can be destroyed 
by a temperature of from 45° to 50° C, if exposed for half an hour. 
It can be destroyed also by a 2 per cent solution of peroxide of hydro- 
gen, by methol and by corrosive sublimate. 

Pathology. — During the last two decades, particularly, great ad- 
vances have been made in the study of the morbid anatomy of polio- 
myelitis. Whereas originally the opinion generally prevailed that 
the lesions of this affection were essentially limited to the anterior 
horns of the spinal cord, it is now definitely settled that no portion of 
the cerebrospinal system may escape involvement, and, moreover, as 
is the case of other grave communicable diseases, the lesions are fre- 
quently disseminated throughout various other structures and organs 
of the body. Since the upper nasal cavities are in direct communica- 
tion with the meninges by means of the lymphatics which pass out- 
ward with the filaments of the olfactory nerve, and since the earliest 
changes are noticeable in the perivascular lymph spaces of the blood 
vessels of the leptomeninges, it seems reasonable to conclude that the 
virus enters the human body through the upper respiratory tract. 
Microscopically the meninges are usually found injected and edema- 



*Of 5,346 cases of poliomyelitis tabulated by the N. Y. City Board of Health during the 
1916 epidemic, the age incidence was as follows: 
6 months or younger 192 cases 

1 year 793 

2 years 1,398 

3 years 1,998 

4 years 693 

5 years 412 



6 years 




245 cases 


7 years 




160 


8 years 




127 


9 years 




78 


10 years 




56 


10 to 15 


years 


94 



DISEASES OF THE NERVE SYSTEM 631 

tous, and the brain and cord moist, translucent and edematous. The 
gray matter of the cord is also swollen and projects above the level 
of the white matter. Minute hemorrhages are often distinguishable in 
both the gray and white matter, the former often assuming a grayish- 
pink hue. The cerebrospinal fluid is but little increased. Microscopi- 
cally the pathologic process is found to consist chiefly of a cellular 
exudation, hemorrhages and edema. The lesions are most pronounced 
where there is an abundance of blood vessels, hence in the cervical 
and lumbar enlargements, more particularly in the anterior horns of 
the cord and in the medulla. "The cellular exudate forms a sheath ap- 
parently completely surrounding the vessels for long stretches and in 
places the cells are so numerous as to form thick collars which seem 
to press on the lumen and thus exert a mechanical effect in obstructing 
the circulation" (Peabody, Draper and Dochez). A similar mechani- 
cal as well as toxic action is progressing in the intimal lining of the 
blood vessels, the conjoint pressure soon leading either to hemor- 
rhagic softening or anemia-pressure-necrosis of the infiltrated struc- 
tures and gradual replacement of the ganglion cells by cicatricial 
tissue. Of course, this terminal pathologic stage is usually not reached 
where the pressure is early relieved by absorption of the hemorrhage 
and cellular exudate ; hence, the large number of mild and so-called 
abortive cases, and the tendency towards spontaneous recovery. In 
recording his observations on human and experimental poliomyelitis 
Howe distinguishes three pathologic types of the disease : (1) Cases in 
which the lesions are limited to infiltration of the pia and blood ves- 
sels: the mesodermic tissue type; (2) cases in which the main feature 
is degeneration of the motor cells in the anterior horn, accompanied 
by the proliferation of neuroglia; the ectodermic tissue type; and (3) 
the mixed type. The first group represents the general reaction of 
the organism to the infection, manifested by changes in the central 
nervous system and the lymph tissues of the body. In the second 
group the changes in the central nervous system of man are poly- 
morphous. The reaction in the ganglion cells and nuclei allows the 
recognition of no less than eight different forms in the degenerative 
process consequent to the poliomyelitis infection. The mixed type is 
usually encountered in human poliomyelitis. As already stated, the 
virus of poliomyelitis is productive also of extensive pathologic 
changes in the lymphoid tissues and parenchymatous organs. Peyer's 
patches and some of the mesenteric glands show lesions resembling 
those observed in typhoid fever. The superficial glands of the body, 
the tonsils, the thymus gland, the liver and occasionally the spleen 
are considerably enlarged. The affected muscles show definite signs 



632 DISEASES OF CHILDREN 

of degeneration. Some of their fibers disappear entirely and others 
are shrunken, the whole limb being atrophied as a result thereof. 
Often the bones participate in this pathologic process. 

Symptomatology and Course.— An affection based upon so vast and 
varied morbid anatomy must obviously manifest itself by an equally 
as complex a symptomatology, ranging between that of simple, local 
and often transient paralysis, and general, frequently fatal, toxemia. 
No wonder that prior to our full understanding of its pathology al- 
most every t} r pe of the affection was described as. a separate clinical 
entity, a disease sui generis. For that matter even the present tend- 
ency to classify poliomyelitis into several distinct tj^pes is hardly 
justifiable from a pathologic point of view; and having had the op- 
portunity to observe a great many cases during the last two epidemics 
and at other times, the author cannot help but feel that no one classi- 
fication will cover all cases clinically. Hence our reason for not attempt- 
ing to present one. 

Initial Stage. — After an incubation period lasting from three to 
twelve days, and towards the end indicated by indefinite symptoms 
of ill health, such as slight fatigue, irritability and anorexia, the tem- 
perature all at once rises, up to 104° F., the child complains of ir- 
regular, muscular pain, headache and sore throat or other symptoms 
of old fashioned grip or is seized with an attack of indigestion, with 
diarrhea and sometimes vomiting, in young children not rarely ac- 
companied by convulsions. Physical examination reveals diffuse 
congestion of the throat, with or without a slight grayish deposit upon 
the tonsils, slight rigidity of the neck, especially on bending the head 
towards the sternum, marked paresthesia, muscular jerking or tre- 
mors, distinct drowsiness, and irritability when disturbed. The mind 
is usually clear even in grave cases. The heart's action is generally 
exaggerated, even when the fever is low. These symptoms may remain 
stationary for from twenty-four to seventy-two hours and then show 
a tendency towards spontaneous abatement (abortive type) or get 
rapidly worse — herald the advent of paralysis. 

Paralytic Stage.— The paralysis usually sets in insidiously, is often 
preceded by progressive muscular weakness and either remains 
localized or swiftly spreads to other parts of the body, the degree of 
severity and extent of the paralysis depending, of course, upon the 
gravity and seat of the lesion. In the majority of cases, especially 
during mild epidemics, the pathologic process is limited chiefly to the 
spinal cord (spinal type). In this event the paralysis usually involves 
the extremities alone, or, less frequently, the neck, abdomen, spine or 
chest as well. The paralysis may be partial or total. The extremities 



DISEASES OF THE NERVE SYSTEM 



633 



are usually affected in the following order of frequency: one leg, both 
legs, one arm, both arms, one leg and one arm on opposite sides or more 
rarely on the same side, both legs and one arm, both legs and both arms, 
and both arms and one leg. Occasionally the paralysis remains limited 
to a group of muscles or even to a single muscle, e. g., the tibialis anti- 
cus, gastrocnemius, or deltoid, and is not rarely overlooked until atrophy 
has set in. When the muscles of the neck are implicated, the child is 
unable to hold the head erect; the latter drops (neck drop) either for- 









J 


I ^*H 


■ i'mT-- 




mm 


1 


i 


£• 






Fig. 182. — Poliomyelitis "spinal 
type;" lesion in lumbar enlargement; 
atrophy and right ( ' drop-foot. ' ' 



Fig. 183. — Poliomyelitis ' ' spinal ' ' 
type; lesion in cervical enlargement; 
paralysis of upper arm as well as right 
serratus magnus, "angel wing" de- 
formity of right scapula, marked mus- 
cular atrophy. 



ward or backward, or sways from side to side. In paralysis of the ab- 
dominal muscles, owing to active intraabdominal pressure by gases, 
there is "ballooning" of the affected muscles which contrasts strongly 
with the flatness of the intact muscles. With the spinal muscles affected 
the patient shows a peculiar clumsiness in turning around or from side 



634 



DISEASES OF CHILDREN 



to side while lying flat on his back, and is unable to assume a sitting 
posture without assistance. This paralysis is ordinarily overlooked un- 
til frank scoliosis has made its appearance. Sometimes the paralysis 
manifests itself in stages, at intervals of several hours, so much so, that 
occasionally the muscles implicated first may already be on the mend 
while a new group of muscles may just about be attacked. Where the 
lesions are limited to the lower neuron the paralysis is flaccid in char- 
acter, the tendon reflexes greatly diminished or lost, the reaction to the 





Fig. 184. — Poliomyelitis ' ' spinal 
type ; ' ' lesion in cervical and dorsal re- 
gions; partial paralysis of the muscles of 
the neck, abdomen, and right thigh 
(atrophy). 



Fig. 185. — Poliomyelitis ' ' spinal 
type ; ' ; lesion in cervical enlargement ; 
' ' neck drop. ; ' 



faradic current lost, while that to the galvanic current may persist for 
some time. Sensation is but slightly impaired. There is no tendency 
to acute decubitus. 

In a small percentage of cases the paralysis, beginning with the lower 
extremities, gradually spreads upward (progressive or ascending type), 



DISEASES OF THE NERVE SYSTEM 635 

resembling Landry's paralysis), involves the upper extremities, the ex- 
ternal muscles of respiration, and the diaphragm, if the lesion reaches 
the upper part of the cervical cord. In this event exitus may take place 
after from two to four days as a result of respiratory failure. On the 
other hand, the paralysis may start in the arms and from here spread 
downwards {descending type, resembling transverse myelitis) to the 





Fig. 186. — Poliomyelitis affecting the Fig. 187. — Poliomyelitis "bulbo- 

abdoniinal muscles giving rise to "bal- spinal type;" lesion in medulla; paraly- 
looning" of the abdomen. sis of left facial nerve, left forearm and 

left leg. 

lower extremities. In these cases we usually find paralysis of the vesical 
and anal sphincters, giving rise to urinary retention or dribbling and 
obstinate constipation or incontinence of feces, respectively. 

In another group of cases the inrlammatory process extends to the 
medulla (bulbospinal type). The lesion is generally unilateral, excep- 



636 



DISEASES OF CHILDREN 



tionally bilateral, and clinically characterized by partial or total paraly- 
sis of some of the cranial nerves, in addition to the manifestations ob- 
served in the purely spinal variety of poliomyelitis. As a rule, the facial 
and abducens are affected, less frequently the glossopharyngeal and 
vagus, and occasionally also the hypoglossal nerve, in which event the pa- 
tient presents not only facial paralysis, inward strabismus, and more or 
less marked respiratory difficulties (Cheyne-Stokes' breathing, cyanosis 




Fig. 188. — Poliomyelitis " pontine ; 



cerebral ' ' type ; lesions in pons, medulla, 



and spinal cord; paralysis of right facial nerve, left forearm and hand, external 
respiratory and abdominal muscles and right leg. 



and cardiac arrhythmia), but also disturbance of phonation and deglu- 
tition. These cases are usually very grave, nay, often fatal within a few 
days. In the absence of concomitant paralysis of the extremities one is 
apt to diagnose laryngeal diphtheria. Indeed, on several occasions the 
author was invited to intubate these cases. "Where the cord remains 
intact and the lesion localized in the medulla alone, the tendon reactions 
are usually exaggerated, the limbs more or less rigid, and there is a 



DISEASES OF THE NERVE SYSTEM 



637 



distinct tendency towards ataxia (ataxic type)* The aforementioned 
symptoms are much more pronounced where the pathologic process in- 
vades also the pons (pontine type), and the condition is further aggra- 
vated by the usual concurrence of oculomotor paralysis which may lead 
to complete ophthalmoplegia, and cross paralysis or hemiplegia al- 
ternans. 

During the recent epidemics ample evidence was brought forth to 




Fig. 189. — Same case as Fig. 188 showing also high degree of scoliosis. 



prove that the so-called primary polioencephalitis (StriLmpell, see Hemi- 
plegia Spastica Infantilis), instead of being a distinct clinical entity, is 
probably a cerebral or encephalitic type of poliomyelitis. As is well 
known, this type of the disease is manifested by the predominance of 
meningeal symptoms, such as recurrent explosive vomiting, convulsions, 
rigidity of the neck up to opisthotonos, and marked stupor. Kernig's 



*Some authors attribute the ataxia to a lesion in the cerebellum ; the postmortem findings, 
however, do not substantiate this claim. 



638 DISEASES OF CHILDREN 

and Brudzinski 's signs are usually inconstant and appear late, and seem 
to be due rather to the resistance on the part of the child to the painful 
flexion of the spine. After a day or two partial or complete spastic 
paralysis of one or several extremities supervenes, not rarely accompan- 
ied by involvement of the facial nerve. In some cases there is also 
marked incoordination of the extremities. The tendon reactions are 
usually greatly exaggerated. 

In the majority of cases pain, either spontaneous or on passive mo- 
tion, forms a conspicuous symptom of acute poliomyelitis. As the pain 
often follows the course of the nerves, as in neuritis, these cases are 
sometimes grouped in a separate class — the polyneuritic type. Accord- 
ing to Lovett, the pain and tenderness are sometimes marked enough to 
cause the paralysis to be entirely overlooked, and a diagnosis of rheu- 
matism or scurvy to be made. In 2 cases under our observation during 
the last epidemic hip- joint disease was diagnosticated. 

Prognosis. — As already stated a great many children fail to survive 
the acute phase of the affection. The mortality seems to vary with the 
virulence of the epidemic. Thus, whereas in the Massachusetts epi- 
demic (1907-10) of 1,599 cases only 125 died, the epidemic of 1916 de- 
stroyed 3,310 young lives in New York State out of a total of 13,177 
victims of poliomyetitis.* The highest death rate, about 63 per cent, 
occurred among the cases in which the lesions extended to the medulla 
and pons, most frequently either as a result of respiratory failure in 
consequence of paralysis of the respiratory muscles, or secondarily to 
complicating bronchopneumonia. Most of them, about 80 per cent, 
succumbed during the first week of the onset of the disease, only 11 
per cent in the second week, 3 to 4 per cent in the third week and about 
five per cent some time later, as a result of exhaustion and complica- 
tions. The highest mortality was noted in children under five or over 
fifteen years of age, higher among males than females. 

Convalescent Stage. — This stage starts with the subsidence of the 
acute symptoms, such as pain and fever, and with the permanent arrest 



*Movement of Cases, Deaths and Fatality Rates from Poliomyelitis During the 
Epidemic oe 1916 in New York State, by Months! 

State of New York New York City Rest of State 

Fatality Fatality Fatality 

Month Rate per Rate per Rate per 

100 100 100 

Cases Deaths Cases Cases Deaths Cases Cases Deaths Cases 

June 367 64 17.4 313 53 20.1 54 1 

July 4,011 895 22.3 3.443 779 22.6 568 116 20.4 

August 5,987 1,466 24.5 3,927 1,080 27.5 2,060 368 17.9 

September 1,992 628 31.5 985 364 37.0 1,007 264 26.2 

October 645 215 33.3 258 122 47.3 387 93 24.0 

November 135 40 29.6 47 25 53.2 88 15 17.0 

December 40 20 50.0 18 11 61.1 22 9 40.9 

Total 13,177 3,310 25.1 8,991 2,444 27.2 4,186 866 21.1 

fM. Nicoll, Jr. (New York State Med. Jour., Vol. xvii, No. 6). 



DISEASES OF THE NERVE SYSTEM 639 

of the paralysis. It corresponds with the stage when the excessive 
exudate in the brain and cord is getting absorbed, the pressure upon 
the vital structures is being spontaneously relieved to a greater or less 
degree, and consequently some of the paralyzed nerves or muscles be- 
gin to functionate. The degree and extent of the initial paralysis is no 
criterion as to the final outcome of the disease as a whole. The author 
has watched many children, seemingly in a hopeless condition, to re- 
cover almost completely, and vice versa, some apparently mild local- 
ized paralyses to persist for life, notwithstanding most scrupulous and 
scientific treatment. The muscles that fail to recover within about ten 
days after the acute attack promptly begin to show signs of atrophy 
(the limb is flabby cold and cyanotic). Associated with the atrophy 
is reaction of degeneration. The response of nerve and muscle to the 
faradic current is usually lost, while the galvanic irritability persists, 
sometimes for a year or two after the onset of the affection. Owing 
to the laxity of the muscles and their inability to hold the articular ends 
of the bones in apposition, the joints soon become the seat of subluxa- 
tions. As the paralysis continues, the trophic changes become more 
and more marked — the limbs lose their shape, often look like mere skin 
and bone, and the growth of the bones becomes retarded. Moreover, 
owing to the activity of the intact, antagonistic muscles, sooner or 
later divers deformities make their appearance. In cases where all the 
muscles of an extremity are uniformly involved, the limb remains free 
from deformity, but is limp and lifeless and hangs attached to the 
trunk like an artificial limb. 

Permanent Stage. — The paralysis may be looked upon as permanent, 
if the case fails to improve after two years' careful treatment. Reaction 
of degeneration of the nerves and muscles is usually complete, and the 
deformities (talipes, scoliosis, etc.) are fully established. The deform- 
ities are generally less pronounced in the so-called cerebral type of 
poliomyelitis. 

Diagnosis. — Typical, spinal, poliomyelitis (i. e., sudden, more or less 
complete, flaccid paralysis of one extremity or several of them, or of a 
group of muscles of the trunk, preceded by moderate fever and other 
symptoms of an ordinary cold or indigestion) usually presents no diag- 
nostic difficulties, whether or not it is met with during the prevalence of 
an epidemic. If pain forms a conspicuous symptom, poliomyelitis may 
in the initial stage be mistaken for scurvy, rheumatic fever, or poly- 
neuritis. Now, in scurvy we generally find a history of a slow onset; 
tumefactions along the long bones, ribs and the bones of the head ; spongi- 
ness and bluish, hemorrhagic discoloration of the gums, and the im- 
mobility of the extremities is due to fear of pain and tenderness but not 



640 DISEASES OF CHILDREN 

to actual paralysis. This latter symptom is characteristic also of rheuma- 
tism. Besides, in this affection the pain is more acute and localized and 
usually associated with some swelling', especially about the joints. Fur- 
thermore, rheumatic fever is not rarely complicated by chorea and endo- 
or pericarditis. Polyneuritis is very uncommon in young children ; as a 
rule, it follows metallic poisoning or serious infectious diseases, is most apt 
to begin with the extensor muscles of the hands and feet, and the symmet- 
rical paralysis does not recede as early as the paralysis of poliomyelitis. 
During an epidemic of infantile paralysis diverse tuberculous and trau- 
matic affections of the bones and joints frequently lead to diagnostic 
errors; however, in doubtful cases a Roentgen-ray examination and 
tuberculin test will readily clear up the diagnosis. Much more diffi- 
culty is encountered in interpreting correctly the other types of polio- 
myelitis, more especially in the absence of an epidemic. Thus, the 
pontine and cerebral types have several symptoms in common with 
acute meningitis and secondary encephalitis. But on closer observa- 
tion it will usually be noted that stupor, Kernig's and Brudzinski's 
signs appear earlier than in poliomyelitis and are also more marked 
and more constant. On the other hand, the paralysis appears earlier 
and is more extensive, as a rule, in poliomyelitis. Furthermore, sec- 
ondary encephalitis follows or complicates some infectious disease, 
e. g., influenza, pneumonia or scarlatina. As errors in the diagnosis 
may prove instrumental in spreading the affection to all others coming 
in contact with the patient, it is wise, where there is the least doubt, to 
proceed with a careful examination of the cerebrospinal fluid. Accord- 
ing to Peabody, Draper and Dochez, who have made an exhaustive study 
of poliomyelitis, the cerebrospinal fluid taken during the early days of 
the disease, and especially before the onset of the paralysis, as a rule, 
shows an increased cell count with a low or normal globulin content. 
At this early stage the polymorphonuclears may amount to 90 per cent 
of the total cells. Later, however, most fluids show almost exclusively lym- 
phocytes and large mononuclear cells. After the first two weeks the cell 
count usually drops to normal, or nearly normal, and there is frequently 
an increase in the globulin content. Analogous changes may be found 
in the spinal fluid of abortive cases. All fluids examined by those 
authors reduced Fehling's solution. As the cerebrospinal fluid of 
poliomyelitis greatly resembles that of tuberculous meningitis, it is 
advisable to exclude the presence of tubercle bacilli in the former. 
Where further confirmation of the diagnosis becomes necessary, we 
may resort also to the colloidal gold reaction of the cerebrospinal 
fluid, which according to Felton and Maxcy is constant and positive 
in the acute stage of poliomyelitis. 



DISEASES OF THE NERVE SYSTEM 641 

While the blood picture of patients suffering from poliomyelitis is 
not as specific as the spinal fluid, it is nevertheless of some diagnostic 
value if taken in connection with other available evidence. There is 
usually a leucocytosis of from 15,000 to 30,000, and the polymorphonu- 
clear cells are increased at the expense of the lymphocytes. 

For the differential diagnosis between polioencephalitis and lethargic 
encephalitis see p. 625. 

Treatment. — Prophylaxis. — With the earliest detection of suspicious 
signs of acute poliomyelitis, the patient should be promptly isolated, 
and handled in the same manner as other communicable diseases (see 
p. 68). During an epidemic, vomiting, fever, headache, diarrhea, con- 
gestion of the throat, rigidity of the neck and drowsiness, should be 
looked upon as suspicious of poliomyelitis. When the diagnosis has 
been confirmed the attendant should be quarantined together with 
the patient for about three weeks. If for financial reasons this proves 
impracticable, it is advisable to remove the patient to a suitable 
hospital. All discharges from the mouth, nose and throat should be 
received on cloths or toilet paper and immediately burned. The feces 
and urine should be disinfected prior to their disposal. The room of 
the patient must be screened to keep out flies, mosquitoes and other 
insects. Before lifting the quarantine, the clothing, bedding, utensils, 
etc., of the patient should be disinfected, and the sick-room and its 
contents thoroughly cleaned and aired. All those known to have 
come in contact with the patient should be carefully watched — for 
about twelve days — for the aforementioned suspicious signs of polio- 
myelitis, and if need be, promptly isolated. During the period of ob- 
servation children should not be permitted to attend school for about 
two weeks. Cleansing of the nose and throat twice daily with anti- 
septic solutions, e. g. } dioxide of hydrogen 2 per cent, is worth trying, 
although it has recently been shown that antiseptics may irritate the 
nasal mucous membrane and render it more susceptible to bacterial in- 
vasion. We may try also the internal administration of hexamethylen- 
amine, as a preventive of poliomyelitis, since it has been proved to find 
its way in the cerebrospinal fluid and to exert a germicidal effect. From 
10 to 15 grains daily, in divided doses, will usually suffice. Whenever 
possible, individuals should occupy beds singly. 

Active Treatment. — 1. Acute Phase. — Absolute rest and quiet to 
body and mind is essential during the acute course of the disease. 
The patient should be kept in bed, in recumbent posture, for about 
ten days, and the affected limbs immobilized, even after apparent 
recession of the paralysis, to prevent early muscular contractures and 
deformities. This is easily accomplished by the application of light 



042 DISEASES OP CHILDREN 

splints, well padded with wadding, to the paralyzed limbs. The feet 
should be supported at right angles to the legs, and in cases where 
the spinal muscles are involved, it is best to put the patient in a Brad- 
ford frame. As in all febrile affections the diet should be nutritious 
and easily digestible, and should consist of broths, boiled milk, fruit 
juices, and well-cooked cereals. Where deglutition is difficult, cautious 
feeding by stomach tube may have to be resorted to. 

No specific has thus far been discovered to combat poliomyelitis in 
any of its forms or stages. Immune serum, supposedly efficient in 
preventing or arresting the progress of poliomyelitis in monkeys, has 
as yet failed to show any appreciable benefits in human beings. 
Nevertheless, for want of more effective therapeutic measures, its use 
should be encouraged, especially in grave cases. If utilized, we must 
be sure that the donor is free from syphilis. The serum is administered 
in the same manner as antimeningitis serum, by lumbar puncture and 
intravenously. It should be injected on three successive days in doses 
of from 15 to 20 c.c. The serum is valuless after the acute stage. In 
rare cases intraspinal injection of serum is folloAved by a reaction 
meningitis. As in other acute cerebrospinal affections, lumbar punc- 
ture is a sovereign remedy also in poliomyelitis, where symptoms of 
brain pressure manifest themselves. It may be employed once or 
twice daily, according to indications. Of medicinal agents, urotropin, 
sodium salicylate and sodium bromide, of each from 3 to 5 grains 
every four hours will generally be found useful. Kespiratory and 
heart failure should be treated with oxygen inhalations, and camphor 
and strychnine or caffeine hypodermically. The author believes that bene- 
ficial results are obtained from the administration of potassium iodide, 
in from 2 to 5 grain doses every four hours ; he assumes that the iodides 
aid in the absorption of the cellular exudation and thus relieve intra- 
spinal pressure. Severe headache may be mitigated by an ice bag to the 
head. High fever may be reduced by warm baths, which are also indi- 
cated in excessive cerebral irritation. Subdural injections of suprarenal 
solutions have thus far proved of no material benefit, and the same is 
true of intravenous injections of salvarsan. 

2. Convalescent Stage. — After subsidence of the acute symptoms 
and complete cessation of the pain and tenderness, an inventory, as 
it were, should be made of the stationary damage to the nerves and 
muscles inflicted by the highly destructive virus. As a rule paralysis 
in some form is left behind. Where the paralysis is partial or limited 
to single muscles, the "spring balance muscle test" may have to be 
resorted to, to determine with any degree of exactitude, how much 
power there is still left in the affected muscles. This test, by the way, 



DISEASES OF THE NERVE SYSTEM 643 

is also of great value to register in pounds, at certain intervals, the 
gain or loss in muscular strength after a certain method of treatment. 
The concensus of opinion of the profession is at present in favor of 
getting the patient in a sitting and, if possible, in an upright position 
as soon as possible, provided the paralysis is not very extensive. Of 
course, this should be done only with the aid of suitable braces, to 
prevent deformities. Where the spinal or abdominal muscles are im- 
plicated, support should be furnished by means of an accurately fit- 
ting light corset, and in cases where the lower extremities are effected, 
the so-called caliper splint should be applied. "Where the glutei are 
also involved, we have to resort to a walking frame and light crutches. 
In paralysis of the deltoid the arm should be supported in a sling, 
and to prevent permanent deformities of the forearm, the latter is 
put in a well-padded wire splint. The less burdensome the splints, 
etc., the better. Furthermore, it is very important not to fatigue the 
patient, whatever method of treatment is adopted. 

To prevent early atrophy and to improve the impoverished circula- 
tion of the structures involved, massage, including vibration, heat, 
electricity and muscle training, including bath exercises, are of un- 
doubted therapeutic value. The treatment should begin after the pain 
and tenderness, spontaneous as well as on passive motion, have com- 
pletely ceased. The massage should be gentle, local as well as general, 
and should be applied once or twice daily for about twenty minutes 
at a time. Later, the massage may be supplemented by light vibratory 
muscular stimulation. The patient should be very warmly dressed, 
and the affected limb should in addition be exposed daily, for ten 
minutes at a time, to dry heat obtained either from a large electric 
bulb or the numerous baking apparatus on the market. The benefits 
derived from the use of electricity have been grossly exaggerated; yet 
a mild faradic and galvanic current, applied for from five to ten 
minutes at a time, every other day, may hasten recovery by inducing 
mild muscular contractions, by improving nutrition and promoting 
conduction of nerve impulses. Muscle training or passive and active 
motion corresponding to the normal muscular action, is the sine qua 
non in the restoration of the muscular functions, but it requires a very 
thorough familiarity with the exact powers of each muscle or group of 
muscles. Otherwise by exercising the muscles in the wrong direction 
considerable harm will be done. Bath exercises also are very beneficial. 
It will sometimes be noted that where patients show no muscular power 
in an extremity, when put into the bath they are able to demonstrate 
some power in those muscles, — the buoyancy of the water apparently 
overcoming the gravity of the limb. As the entire cooperation and con- 



644 DISEASES OF CHILDREN 

centration of attention of the patient is indispensable to its successful 
performance, muscle training is only applicable in children over five 
years of age. Furthermore, this mode of treatment is best entrusted 
to an expert in this line of work. 

A number of clinicians claim to have obtained excellent results 
from the injection of strychnine in the paralyzed muscles. This treat- 
ment was originally recommended by Charcot. He administered, 
once daily, 1/40 to 1/50 grain. As strychnine in small doses is a useful 
general tonic, it can do no harm and possibly may do some good. It 
may advantageously be combined with the glycerophosphate of iron. 
General supportive treatment, ample, nutritious food and fresh out- 
door air are excellent adjuvants in the reestablishment of the dor- 
mant bodily functions. 

3. Permanent Stage. — If after giving the aforementioned methods 
of treatment faithful trial without any appreciable benefit to the pa- 
tient, but on the contrary the paralysis persists and the deformities 
become fixed, there is nothing else left but to attempt to correct the 
deformities by operative procedures. The profession is not agreed 
on the time when an operation becomes indispensable. Some surgeons 
advise waiting two years, others twice as long or even longer. Hence 
it is best to leave the decision of this important question to the good 
judgment of the individual surgeon. As to the choice of the particu- 
lar operations, R. W. Lovett offers the following suggestions: 

Talipes Equinus. — Stretching, tenotomy of the tendo Achillis, if the 
anterior muscles have fair power. Transplantation of the extensor of 
the great toe or other extensors into the tarsal bones, anterior silk liga- 
ments with or without tenotomy, tenodesis, arthrodesis. 

Talipes Calcaneus. — Astragalectomy, tenodesis, arthrodesis. 

Talipes Varus. — Transplantation of the anterior tibial, when that is 
active, to the outer third of the foot. Silk ligament from the fibula to 
the cuboid; astragalectomy, tenodesis, arthrodesis. 

Talipes Valgus. — Transplantation of one of the peroneals to the 
inner side of the foot, silk ligaments from the tibia to the inner side of 
the tarsus; astragalectomy, tenodesis, arthrodesis. 

Flexed Knee. — Stretching or open division of the hamstrings. 

Hyper extended Knee. — In cases where the quadriceps is paralyzed 
and the hamstrings and the gastrocnemius are good, transplantation of 
one or two hamstrings into the tubercle of the tibia. 

Knock-knee. — Supracondyloid osteotomy (Soutter's operation). 

Flexed Hip. — Fasciotomy, if severe. 

Dislocated Hip. — Arthrodesis. 



DISEASES OF THE NERVE SYSTEM 645 

Shoulder. — Dropping of the arm away from the glenoid cavity, ar- 
throdesis of the joint, silk ligaments. 

In cases of deltoid paralysis with the pectoralis major active, the 
origin of the latter may be transplanted into the spine of the scapula. 

The operations on the forearm, elbow and wrist vary greatly in in- 
dividual cases. Arthrodesis of the elbow is useful, but the operation is 
not applicable at the wrist on account of the nature of the joint. 

Scoliosis. — Treated in the same manner as scoliosis due to other 
causes than poliomyelitis. 

It is essential to the success of these operations to select a surgeon 
who is thoroughly familiar with this work. But even in the best hands, 
the results are not invariably good. This is especially true of cases 
which have been greatly neglected or treated by the numerous quacks 
who thrive upon the ignorance of the unfortunate people. 

Tumors of the Brain 

Of the total number of cases of brain tumors on record about one- 
half occurred in children. It is more common in boys than in girls. 
The usual seat is in the cerebellum and the basal ganglia. Brain tu- 



i* 1 

m 



.1 






w .> 



x§ -. 



IS 



Fig. 190. — Secondary passive hydrocephalus in tumor of the brain. (O. Yierodt, 
Pfaundler and Schlossmann.) 

bercle is especially common, and relatively frequent also are divers 
forms of sarcoma (gliosarcoma). These are often metastatic. Hidden 
as intracranial neoplasms are from sight and touch, their nature must 
necessarily be a matter of conjecture only, except, perhaps, in cases 
of bony growths, which may be diagnosed by means of the Roentgen- 
ray, and tubercle and syphilis which may be surmised by the presence 
of other tuberculous or syphilitic lesions in other parts of the body or 
detected by the tuberculin, complement fixation, or AVassermann tests. 



646 DISEASES OF CHILDREN 

The diagnosis of brain tumor is based upon the general and local 
nerve disturbances they produce. As a rule, the general symptoms 
precede the local, and consist of headache, vomiting, vertigo, optic 
neuritis, and convulsions. 

The headache is usually persistent, but may also be periodical, sug- 
gesting a malarial origin. The headache may be frontal, vertical or 
occipital, or equally distributed over all parts of the cranium. The 
locality of the pain occasionally bears a direct relation to the seat of 
the tumor, thus, when the growth is in the white substance the pain 
is usually frontal; when beneath the tentorium, occipital, etc. The 
same rule often applies to the pain elicited on tapping the skull over 
the seat of the disease. Intense headache in infants is indicated by 
rolling of the head from side to side, by throwing up the hands to the 
head, contraction of the eyebrows, and intolerance to light. The 
headache is frequently followed but may also be preceded by vomit- 
ing. 

The vomiting is projectile in character, and comes on suddenly. 
It differs from gastric vomiting by the absence of other signs of 
stomach trouble, and from vomiting accompanying migraine by that 
the headache does not always terminate with it. Vomiting is espe- 
cially characteristic of tumor in the medulla oblongata or the middle 
lobe of the cerebellum, but it may occur in tumors affecting any part 
of the brain. 

The vertigo may be constant or paroxysmal and is most marked in 
affections of the pons or cerebellum. Vertigo in infants frequently 
escapes notice. It is manifested by sudden drooping of the head, pal- 
lor of the face and occasionally also vomiting. 

Optic neuritis sometimes forms one of the earliest symptoms of 
brain tumors. It does not always correspond to the size of the tumor. 
The choked disc is usually bilateral. It may develop slowly or rap- 
idly, and in either case the optic neuritis proceeds to complete optic 
atrophy. 

The child's nervous system being highly susceptible to irritation, 
increased intracranial pressure is quite early productive of convul- 
sions of varying severity. The convulsions may be general or local. 
General convulsions with loss of consciousness may occur in tumors 
of any part of the brain, but are more common in tumors of the 
posterior fossa than in those of the anterior or middle fossa. Local 
convulsive seizures are met with chiefly when the neoplasm occupies 
certain situations. For example, convulsions beginning in the foot, 
as a rule, are indicative of the lesion being in the upper region of the 
motor area; those of the arm, the middle region; and those of the 



DISEASES OF THE NERVE SYSTEM 647 

face, the lower region. It should be remembered, however, that the 
effects of a tumor may extend far beyond its actual site. and. further- 
more, as the case proceeds, convulsions, which from the outset have 
been local, may become general. The convulsive attacks may recur 
frequently and last from several seconds to as many hours. The con- 
vulsions are not rarely followed by paresis or paralysis of the affected 
limbs. At first the muscular weakness may be transient, but as the 
disease advances it becomes permanent. 

The focal symptoms of brain tumors are also manifested by uni- 
or bilateral hemiplegia, monoplegia, affections of speech, and paraly- 
sis of cranial nerves. (See "Brain Localization" p. 602.) The local 
symptoms pointing to the seat of the tumor attain their greatest preci- 
sion when the swelling — be it a new growth or an inflammatory mass — ■ 
is seated in the motor area of the cortex. They do not always correspond, 
however, to the size of the tumor. Furthermore, as the brain usually ac- 
commodates itself gradually to the increasing pressure and functional in- 
terference produced by the new growths, the appearance of the focal 
symptoms is frequently delayed until a very late stage of the disease. 
Once established, local symptoms are of great help in arriving at a correct 
diagnosis, except, perhaps in cases where the tumor is multiple and 
distributed through various parts of the brain. (See "Tuberculosis 
of the Brain," p. 452.) 

Diagnosis. — With the determination of the seat of the tumor, the diag- 
nosis is greatly facilitated but rarely entirely settled. Brain tumors have 
several symptoms in common with tuberculous and syphilitic men- 
ingitis, brain abscess, epilepsy and hysteria. The differentiation be- 
tween tuberculous and syphilitic tumors, and chronic tuberculous and 
syphilitic meningitis is extremely difficult and often impossible espe- 
cially when the tumors are multiple. In tubercle and gumma the 
symptoms are more gradual in development, the optic atrophy more 
pronounced, and the focal symptoms more marked and localized, 
while the course of tuberculous or syphilitic meningitis is much more 
rapid and, besides, there are several other symptoms pathognomonic of 
meningitis. In doubtful cases some valuable information may be ob- 
tained from the tuberculin and \Yasserniami tests and from a careful 
examination of the cerebrospinal fluid. In acute brain abscess optic 
atrophy is absent, there is usually a history of acute infection, ear dis- 
ease, or trauma, and the symptoms of purulent encephalitis, such as 
chills, fever, stupor, etc. In the absence of this history there is practi- 
cally no way of distinguishing latent chronic abscess from tumor, as has 
already been emphasized on a previous occasion (p. 623). 



648 DISEASES OF CHILDREN 

Jackson ian epilepsy may resemble brain tumor in its early stage, 
but as the disease advances the diagnosis can readily be cleared up 
by the absence of optic neuritis and other focal symptoms. There are 
cases on record of hysterical hemiplegia with convulsions and contrac- 
tures which were mistaken for brain tumor. Careful investigation, how- 
ever, will usually reveal the absence of optic neuritis, and the fact that 
in hysteria the symptoms are inconstant and multifarious, rather sud- 
den in development, and rarely progressive in character. 

The nature of the tumor can sometimes be established by its seat. 
Thus, if the tumor is located in the cerebellum or pons, it is probably 
tubercle or glioma; if in the cortex, it is apt to be syphilitic. Cysti- 
cerci are most commonly met with in the meninges or cortex. Abscesses 
are usually situated in the cerebral or cerebellar "hemisphere," and 
but rarely in the central ganglia, the pons, medulla, or the middle 
lobe of the cerebellum. Too much reliance, however, cannot be placed 
upon these observations. 

Treatment. — In view of the possibility of the tumor being syphilitic, it 
is always advisable to put the patient on an active antisyphilitic course of 
treatment (the iodides and mercury). In syphilitic disease prompt 
treatment will soon be followed by amelioration of the symptoms, and, 
if faithfully persisted in, often by a cure. This therapeutic measure 
is occasionally attended by favorable results also in growths other 
than syphilitic, and should, therefore, be resorted to as a -routine 
procedure in all obscure brain lesions. Antisyphilitic treatment prov- 
ing negative, and tonics, in the form of fresh air, generous diet, cod 
liver oil, iron and the hypophosphites, failing to benefit the patient, — 
tonic treatment may do well in tubercle, and if employed early may in ex- 
ceptional cases arrest its growth, — the question of surgical interfer- 
ence should be taken under advisement. An operation is indicated 
where the tumor is single, and situated superficially in a part of the 
brain (motor area of the cortex) which can be reached and from 
which the tumor can be removed without immediate danger to life. 
Under favorable conditions, an operation should be performed early, 
before the general health has greatly suffered and permanent injury 
has resulted to organs and limbs from persistent brain pressure. Re- 
cently successful attempts have been made to remove growths from 
deeply seated structures ; the results as to life and good health, how- 
ever, are still too few and too far between to warrant precipitate action. 

In hopeless cases morphine and its derivatives will help to relieve 
the agony. (For "Tumors of the Pituitary Gland," see p. 570.) 



DISEASES OF THE NERVE SYSTEM 649 

Epilepsia 

(Epilepsy; Fits) 

Epilepsy is an obscure affection of the brain, in typical form char- 
acterized by attacks of loss of consciousness, local or general con- 
vulsions, and a great tendency toward psychic disturbances. The 
situation and exact nature of the brain lesion is still undetermined, 
but, judging from the pathologic alterations (atrophy, hypertrophy, 
abscess formation, sclerosis, porencephalia, retention of subcortical 
cells, changes in the blood, etc.) so frequently found postmortem, 
there is reason to believe that there is no one pathologic entity re- 
sponsible for the morbid condition. 

The causes of epilepsy are many and divers. Congenital defects of 
the brain or skull; traumatism to the brain or skull (during birth or 
after); infectious diseases affecting the brain directly or indirectly; 
toxemias of all kinds, including grave gastrointestinal intoxication; 
repeated attacks of convulsions from reflex causes; neoplasms, in- 
cluding syphilitic and tuberculous ; sudden psychic disturbances, such 
as sudden shock, etc., among many other as yet obscure causes, all 
contribute their share toward development of epilepsy at some period 
of life. An hereditary disposition is traceable in a certain number 
of cases, and children of syphilitic, alcoholic, and neurotic parents 
are more prone to contract the affection than those free from such 
encumbrances. 

No age is exempt from the disease, but it is most apt to develop in 
children of from two to fifteen years old. 

The exact time of the beginning of the disease cannot always be 
traced, since the symptoms may be so mild as to escape observation. 
The child may for a few moments "hang its head," turn pale, and the 
paroxysm would be over with — hardly any reason to suspect epilepsy. 
The little attack may not recur for weeks or months, so that the last 
one is long forgotten when the next one sets in. It is only after the at- 
tacks grow longer in duration, stronger, more frequent, are preceded 
by an aura and possibly followed by involuntary urination and de- 
fecation, and profound sleep, that the nature of the dreadful condi- 
tion is fully realized. 

Genuine epilepsy varies greatly in severity not only in different 
individuals but also at different times. In addition to the rudimen- 
tary forms later to be described, the paroxysms are generally classi- 
fied into severe (grand mal), mild (petit mat), and cortical or Jack- 
sonian. The attacks are frequently preceded by a warning (aura) of 
motor, sensory or vasomotor character. There may be slight twitchings 



650 DISEASES OF CHILDREN 

of the limbs, eyes, or head, slight general tremor, a vague sensation in 
the stomach, a feeling of numbness or pricking in the extremities, hear- 
ing of noises, seeing of colors or sparks, smelling of peculiar odors, 
irritability, hallucinations, etc. 

In grand mal immediately following the aura, and also without 
it, the patient, who may appear to be in good health, suddenly cries 
out, loses consciousness and falls, and becomes fixed in a tonic spasm, 
with face and limbs contorted and breathing suspended. His face is 
pale or cyanotic; his eyes are widely open (pupils usually dilated) 
and staring or rolled upward or sideward. The teeth are pressed 
firmly together, with the tongue often impacted between them. In a 
moment the fixed spasm gives way to clonic convulsions. The face, 
bod}' and extremities twitch violently, and the head beats strongly 
backward. During this stage the face is congested and often bathed 
in perspiration. Foam frequently fills the mouth, and may be mixed 
with blood from the severely bitten tongue. As the contractions 
cease, the child sinks down exhausted, limp and lifeless — except for 
deep sighing respiration- — into a state of profound sleep (postepilep- 
tic coma) of variable duration. With return of consciousness he has 
no knowledge of what occurred. The duration of the paroxysms 
varies between one and five minutes. It may occur once or several 
times a day, a week or month, or may not return for several months 
and even years. A certain periodicity, however, is demonstrable in 
a great many cases. The attacks may also occur at night, during sound 
sleep. 

Petit mal is usually manifested by sudden loss of consciousness of 
very short duration. The patient may turn pale, stare vacantly, 
twitch a little, drop what he is holding, and then recover himself. 
Often in the midst of play the child suddenly stands fixed, "as if 
bewitched, ' ' with staring, absent-minded facial expression ; a few mo- 
ments later he resumes his play as though nothing had happened, or sinks 
down feebly or runs toward some object or person to support him- 
self. The transition (sometimes after years) of petit mal into grand 
mal is not rare, and should always be remembered in fixing the dura- 
tion of epilepsy. 

In another group of cases the convulsions begin in one particular 
muscle or group of muscles, and rapidly spread to other parts of the 
body. Loss of consciousness may be absent or occur after the con- 
vulsions have become general. It is often followed by localized pare- 
sis. This cortical or Jacksonian form of epilepsy is based upon a defin- 
ite local lesion in the cortex ; it is acquired, whereas general convulsions 
may be both of prenatal or postnatal origin. 



DISEASES OF THE NERVE SYSTEM 651 

Epilepsy is not always represented by so typical a clinical picture. 
Rudimentary forms are encountered, which may tax the skill of even 
the best observer in reaching a correct conclusion. 

In children as in adults instead of typical or atypical attacks of 
morbid physical phenomena, momentary states of mental disturbances 
may occur which may vary from simple confusion up to acute mania. 

These fits occasionally alternate with convulsive seizures. Less 
common than in adults are the so-called postepileptic, frequently 
rather preepileptic, psychical aberrations which are manifested by 
unconscious, automatic, more or less violent actions, lasting minutes, 
hours or days. Inexplicable disappearance of children from home is 
not rarely an epileptic manifestation. 

Epilepsia nutans ("Salaamkrampf ") is manifested by sudden 
lightning-like spasmodic forward movements* (between 20 and 100) 
of the upper part of the body — a sort of reverential bow — and is as- 
sociated with partial or complete loss of consciousness. 

Epilepsia procursiva is characterized by a sudden forced start of 
running, of variable duration, which may cease abruptly or end in an 
attack of convulsions. Consciousness is partially lost during this 
seizure. 

Epilepsy sooner or later leads to permanent mental impairment. 
In the earlier stages this may consist only of weakness of memory, 
silliness, alteration in the behavior (the child may be cranky, quarrel- 
some, destrucive, etc.), but as the disease becomes chronic the pa- 
tient's mental dulness increases and may reach a state of total idiocy 
(see p. 751). Furthermore, with the growing mental hebetude there 
is also a corresponding development of coarse features with a down- 
cast, dazed, and stolid facial expression — physical peculiarities which to 
the keen observer often betray some hidden central lesion. This obser- 
vation often serves well in the differential diagnosis between epilepsy 
and reflex and hysteroid convulsive paroxysms. (See Spasmophilia 
and Hysteria.) 

Treatment. — The termination of epilepsy is subject to great varia- 
tions. With the recent gradual improvement in the methods of diag- 
nosis and treatment, complete recover}^ from genuine epilepsy is far 
from being exceptional. This refers particularly to cases due to reflex 
causes (defective vision, adenoids, worms, phimosis, etc.), when de- 
tected early and remedied. To a great extent this is true also of cases re- 
sulting from traumatism or benign neoplasms, which are nowadays op- 
erated upon more or less successfully. The surgical results are especially 
gratifying in the Jacksonian form of epilepsy. Operative interfer- 



* Similar forward movements are frequently observed in divers forms of idiocy. 



652 DISEASES OF CHILDREN 

ence, however, should always be preceded by an antisyphilitic course 
of treatment, which not rarely acts admirably. Some cases of epil- 
epsy after resisting all sorts of " cures" for a number of years get 
well as unexpectedly as they got sick. Others again persist for life, 
do what you may. This is the so-called idiopathic epilepsy, for which 
from time immemorial the whole pharmacopeia, witchcraft, mental 
healing, Christian or unchristian Science, etc., have been used in vain. 
What can be accomplished, however, in such cases is the lessening of 
the severity and frequency of the attacks. All sources of irritation, 
however trifling, should be removed. The patient should be placed 
on a light, salt-free diet (milk, bread, cereals, vegetables, custards; 
eggs, fish; occasionally well-boiled meat; plenty of fruit and water) 
under the best possible hygienic conditions, and in the most congenial 
and restful surroundings. Residence in the country, with plenty of 
outdoor air, moderate exercise and hydrotherapy are ideal adjuvants. 

If preceded by an aura sometimes in advance of the fit, the latter 
may occasionally be aborted by inhalation of amyl nitrite. 

Immediate attention should be paid also to the convulsive fit, not 
alone to prevent a fatal issue from cerebral hemorrhage, or possibly 
from apnea, but principally to avoid grave bodily injury which the 
patient is apt to sustain during a severe fit. "When the attacks are 
of frequent occurrence the child should not be left alone, especially 
in a room with an open fire, or in the vicinity of ponds, rivers, rail- 
road tracks, etc., lest he be suffocated, fall out of bed, set himself on 
fire, drown, etc. A handkerchief or cork should be placed between 
the child's molar teeth to prevent biting of the tongue. A severe con- 
vulsive seizure may be aborted or modified by a few whiffs of chloro- 
form, or amyl nitrite. 

Of all remedies thus far recommended the bromides are the only 
ones which have proved of actual benefit in all forms of epilepsy. 
We should begin with moderate doses that w T ill control the paroxysms. 
The bromides may advantageously be combined with small doses of 
Fowler's solution of arsenic. The treatment should be continued, 
with brief intermissions, to avoid bromism, for years — long after 
c 



essation of the attacks. 



Iy Katrii Bromidi 

Ammonii Bromidi aa 3 ii 

Strontii Bromidi 3 i 

Liquor Potassii Arsenitis 3 ss 

Mist. Eliei et Soda? 3 ss 

Syr. Aurantii q. s. ad f 3 iii 
M. 

S. — One teaspoonful in water every six hours, 

and later only twice a day, for a child six years old. 



8.00 

4.00 

2.00 

15.00 

90.00 



DISEASES OF THE NERVE SYSTEM 653 

Iii severe fits we may add small doses of codeine. 

When the bromides are not well tolerated by the stomach they 
may temporarily be administered per rectum. Postepileptic out- 
breaks frequently yield to early administration of hypnotics, espe- 
cially chloral. Of late considerable success has been claimed from the 
administration of luminal (phenylethylbarbituric acid) in 1 gr. to 2 
gr. doses, once or twice a day. It is supposed to be a non-habit-forming 
hypnotic and free from other deleterious effects. It is prescribed instead 
of or alternating with the bromides. 

Migraine, Hemicrania 

(Sick Headache) 

There is reason to believe that the seat of the irritation upon which 
depend the pain and other manifestations of hemicrania lies in the 
brain (in the cortex or deeper cerebral structures). Cerebral hyper- 
emia or anemia seems to be the immediate cause of an attack. The 
remote causes are very numerous. Gastrointestinal autointoxication 
seems to play a prominent role, and eyestrain, nasopharyngeal ab- 
normalities, dental caries, helminthiasis, infectious diseases, and 
general debility are often found to act as predisposing causes. The 
disease prevails chiefly among nervous children over eight years of 
age, in girls more frequently than in boys. To some extent it seems 
to be hereditary. 

Similar to epilepsy, migraine shows a distinct periodicity and is 
frequently preceded by premonitory signs, consisting of depression, 
irritability, visual disturbance, tremor, nausea and vomiting. The 
child complains of violent headache, usually along half of the head 
(hemicrania) or occiput. The pain is increased by jars, light, and 
noises, may last several minutes, hours, or days, and frequently ter- 
minates with an attack of vomiting followed by sound sleep, from 
which the patient awakes very much refreshed and apparently per- 
fectly well. A prolonged attack is not rarely accompanied by psychic 
disturbance and even slight convulsions, in which event it may re- 
semble organic brain disease, e. g., tuberculosis of the brain. The 
paroxysms may return after weeks, days, or months, at all events the 
disease runs a very chronic course, especially if no energetic efforts are 
made to determine the underlying cause and to remove it. 

Treatment. — Where the cause cannot be detected or removed, a 
great deal of benefit is usually derived from improvement of the gen- 
eral health, especially attention to existing anemia, constipation, etc., 
and regulation of diet. Dilute hydrochloric acid (5 drops, well di- 



G54 DISEASES OF CHILDREN 

luted, after each meal) often acts ver}' beneficially. Sojourn in the 
country. 

During- an attack the patient should be kept quiet in bed, in a dark, 
well-ventilated room. Local moist heat, and caffeine and quinine (in 
cerebral anemia), and phenacetin and ergot with sodium bromide (in 
cerebral hyperemia) are of service to relieve the intense pain. 

IJ Natrii Bromidi 3 i 4.00 

Antipyrinre 

Caffeinse Natrii Benzoatis aa 3 ss 2.00 

Syr. Aurantii q. s. ad f § ii 60.00 

M. 

S. — One teaspoonful every six hours, for a child 
six years old. 

Pavor Nocturnus 

(Night Terrors) 

Night terrors are observed chiefly in nervous children of from 
three to eight years old. Probably frightened by a horrible dream 
(seeing ferocious animals, etc.), the child suddenly awakes, jumps up, 
sits up in bed or jumps out, looks around staringly and anxiously, 
cries or screams for help, or utters incoherent words. After a few 
minutes he recognizes those about him, quiets down and falls asleep. 
The attack may recur once or more times a night or at longer inter- 
vals, and ultimately disappears (sometimes not until puberty )-without 
serious consequences. In rare instances pavor nocturnus forms a 
precursor of epilepsy. I am inclined to think that the immediate 
cause of the attack is a cerebral hyperemia. 

As a rule, the attack is aggravated by overloading of the stomach be- 
fore retiring, faulty feeding, hearing of fearful stories, or seeing exciting 
shows, the presence of intestinal worms, adenoids and hypertrophied ton- 
sils, and other local disturbances, and usually ceases upon removal of the 
aforementioned causes. The patient should sleep in an airy, slightly 
illuminated room, on a hard mattress, lightly covered and free from 
tightly fitting night clothes. The general health should be improved 
by outdoor air, cod liver oil, and other tonics. A moderate dose of 
sodium bromide at bedtime is useful to check frequently recurring at- 
tacks. 

Syringomyelia-' 

Cavities in the cord may occur primarily as a congenital arrest of 
development or secondarily as a result of a gliomatous process in 



*For "Congenital Malformations of the Spinal Cord," see p. 197. 



DISEASES OF THE NERVE SYSTEM 655 

the gray (cervical enlargement ) and white matter. In pronounced 
noncongenital cases it is manifested by gradual loss of power in the 
upper limbs, trophic disturbances in the skin, subcutaneous tissue, 
and bones (glossy skin, ulceration and necrosis of the phalanges), 
disturbance of sensibility (partial or complete loss of pain- and tem- 
perature-sense while the muscular and tactile senses are preserved). 
Later, signs of muscular atrophy — beginning with a small muscle of 
the hand and gradually extending up to the shoulder— and paralysis, 
first of the upper then of the lower extremities, set in. The course of 
the disease is slow and occasionally interrupted by stationary periods. 

Spinal Hemorrhage 

(Apoplexia Spinalis, Heviatomyelia) 

The hemorrhage may be outside the dura, in the membranes, or 
in the substance of the cord. It is usually of traumatic origin — in- 
strumental delivery, a fall or blow, or severe convulsions. The his- 
tory of the case, therefore, is valuable in the diagnosis. Slight hemor- 
rhage may give rise to no definite symptoms. The diagnosis of severe 
hemorrhage is based upon the sudden appearance of intense pain in 
the back, rigidity of the spine, sometimes convulsions, blood in the cere- 
brospinal fluid, and, if the pressure upon the cord is marked, para- 
lytic symptoms. (See "Myelitis," p. 656.) The latter are especially 
pronounced in hemorrhage into the gray substance of the cord. Where 
the hemorrhage is moderate and the patient survives the immediate 
attack, the tendency of the affection is toward recovery. This may 
be enhanced by absolute rest on the face or side in a somewhat prone 
position. Local abstraction of blood; ice to the seat of injury. Later 
attention to the palsy. Cases due to fractures and direct violence 
must be treated surgically. 

Spinal Meningitis 

In the majority of cases inflammation of the meninges of the spinal 
cord is associated with that of the brain. (See "Cerebrospinal Men- 
ingitis".) Occasionally, however, the inflammation is limited to the 
spinal membranes, similar to spinal hemorrhage, being produced by 
traumatism. 

The symptoms of spinal meningitis are practically the same as 
in spinal hemorrhage, except that the former affection is marked by 
a sharp rise in temperature at the onset, and by a more progressive 
character of the symptoms. Absolute recovery is exceptional. The 
treatment is symptomatic. 



656 DISEASES OF CHILDREN 

Myelitis 

This affection is occasionally observed in children principally as a 
result of traumatism, syphilis and compression of the cord by tuber- 
culous masses and exudates between the dura and vertebrae second- 
arily to spondylitis. The pathologic process in the cord varies with 
the etiologic factors. Ordinarily the diseased portion is at first red 
and soft, and later, yellow, fatty degenerated, atrophied and scle- 
rosed. The lesion may be situated in any part of the cord and accord- 
ingly the symptoms differ with the localization. Thus, in disease of 
the cervical region there is first involvement (motor paralysis and sen- 
sory disturbances) of the upper extremities, then of the lower, and, if 
the lesion is very high up, the diaphragm also is affected and respira- 
tion is interfered with. In disease of the dorsal portion there is para- 
plegia (with muscular rigidity), with exaggeration of the reflexes, anes- 
thesia of the extremities, paralysis of the bladder and rectum and 
decubitus. In myelitis of the lumbosacral region the paralysis, etc., is 
the same as in the former lesion, but the muscles are flaccid, show de- 
generative changes to electric tests, and waste, and the skin and tendon 
reflexes are abolished. The feet fall into an extended position, so that 
the instep is on a line with the tibia. In partial myelitis the symptoms 
are less pronounced, extending only to such structures as are innervated 
by the diseased segment of the cord. In unilateral lesions the symptoms, 
of course, are limited to the affected side. 

The onset may be sudden or slow, according to cause. Acute cases 
set in with chills, moderate fever, nausea, sometimes vomiting and con- 
vulsions, radiating pain in the back and legs, rapidly followed by the 
aforementioned signs. Cases with gradual onset, e. g., secondarily to 
spondylitis or compression by extraspinal growths, are manifested by 
gradually progressing debility of the muscles supplied by the spinal 
nerves below the compressed area (see p. 168), neuralgic pain, and dis- 
turbance of the bladder. 

If the primary affection (e. g., tuberculosis, syphilis) can be reached 
and remedied before destruction of the cord has advanced too far, the 
progress of the disease can readily be arrested. Otherwise the symptoms 
continue to grow worse and at best can only be improved by massage, 
passive motion and faradization, procedures which are generally em- 
ployed in all forms of chronic paralysis. Attention should be paid to 
the bladder (catheterization) and bowels, and particularly to the skin, 
as the tendency to the development of bed sores is very great. 



DISEASES OF THE NERVE SYSTEM 657 

Ataxia Hereditaria (Friedreich), Heredo- 
ataxie Cerebelleuse (Marie) 

This family affection which is traceable through several generations. 
is of obscure origin. Syphilis in the parents is most probably the 
cause. The anatomic lesion — degeneration — is situated principally 
in the cord (the column of Goll. and partly also of Burdach and 
Clarke) and in some cases also in the cerebellum. The cord as a whole 
is very thin and small, i. e., arrested in development. 

The disease attacks the patient insidiously, between the sixth and 
fifteenth years of life, with symptoms of simple progressive incoordina- 
tion of the lower limbs, trunk and arms — irregular swaying resembling 
that of chorea. Later also nodding of the head. Gradually the tabetic 
cerebellar gait develops, so that the child is ultimately unable to walk 
or stand. As the disease progresses, speech becomes peculiar, slightly 
scanning, heavy and awkward, vision disturbed by nystagmus, and ex- 
ceptionally by optic atrophy (Argyll-Robertson symptom is absent, while 
Romberg's is occasionally present), the face expressionless, the general 
musculature paralyzed, atrophied, the spinal column curved, the feet 
humpy looking with the toes turned up [Friedreich's foot), and, finally 
intelligence impaired. Unprovoked and uncontrollable laughter is said 
to be characteristic of the disease. As a rule, sensation and the cutane- 
ous reflexes remain undisturbed: the sphincters are intact until very 
late, while the tendon reflexes are abolished. The course of the disease 
is very chronic. The patient is usually bedridden after a period of 
from five to ten years, but he may continue to live in this state for an- 
other ten years. 

Disseminated Sclerosis 

(Multiple Sclerosis) 

The etiology of diffuse and disseminated sclerosis is not definitely 
known. It is either congenital, and traceable to alcoholism or syphilis 
in the parents, or is met with in young, apparently healthy and normally 
developed children some time after traumatism or an attack of an in- 
fectious disease. 

Its onset is usually insidious with disturbances of motion, loss of 
memory, and dulness of intellect, soon to be followed by defective 
speech (at first slow and later scanning), hearing, and vision (nys- 
tagmus, amaurosis, and strabismus), spastic paraplegia (weakness and 
rigidity first of the upper extremities, then of the lower; exaggerated 
tendon reaction and ankle clonus) and intention tremor. In the later 
stages of the disease the patient loses control of the bowels and 



G5S DISEASES OP CHILDREN 

bladder, suffers from difficult deglutition, attacks of vertigo, loss of 
consciousness and convulsions, and finally enters into a state of mental 
and physical exhaustion, paralysis and idiocy. Death occurs after 
several years. 

The symptoms just enumerated do not all prevail in every case. 
They differ with the location of the sclerosed patches. As a rule, the 
latter are found not only in the brain but in the medulla and spinal 
cord as well — chiefly in the white substance. 

Treatment. — The disease is very rarely influenced by treatment. 
Antisyphilitic medication, however, is worth trying. 

HEREDITARY PROGRESSIVE MUSCULAR ATROPHIES 

(I. SPINAL; II. NEURAL; III. MYOGENIC) 

This classification is intended solely to emphasize the principal 
locations of the underlying lesions. This disease is transmitted from 
generation to generation and often affects several members of the 
same family. 

I. Spinal Progressive Muscular Atrophy 

It is observed in early infancy. It begins with weakness of the 
muscles of the legs, neck, back, throat, shoulders, arms, hands, fingers 
and toes. As the disease advances the muscles are completely atro- 
phied (rarely pseudohypertrophied) so that the child is entirely help- 
less. The reflexes are abolished and the electric reaction greatly dis- 
turbed. The disease ends fatally within about four years from in- 
volvement of the respiratory muscles and consecutive pneumonia. 
The lesion consists of atrophy of the cells of the anterior cornu of the 
entire spinal cord and degeneration of the motor nerve fibers. There 
is no central involvement, hence, cerebral symptoms are absent. The 
sphincters are intact. Fibrillar twitching is infrequent. 

II. Neural Progressive Muscular Atrophy 

(Peroneal Type) 

It is characterized by atrophy beginning with the muscles of the legs, 
especially the peroneal group, and by predominence of sensory dis- 
turbances, hyperesthesia or anesthesia. In walking the child lifts the 
feet high and touches the floor with the tips. If the muscles of the 
hands are affected, the hands become claw-shaped. Occasionally other 
muscles are implicated. The patellar and Achilles' tendon reflexes 
are at first diminished and later abolished. The electric reaction of 



DISEASES OF THE NERVE SYSTEM 659 

the atrophied muscles varies — is normal in some cases, disturbed in 
others — irrespective of the nature of the atrophy. Fibrillar twitchings 
are common. The course of the disease is very slow and interrupted by 
remissions of variable length, and judging by the underlying pathologic 
anatomy of the affection (degeneration of the respective peripheral 
nerves, with slight implication of the spinal cord) it is per se probably 
not fatal. Massage, baths and electricity are of benefit. 

III. Myogenic Progressive Muscular Atrophy 

(Dystrophia Muscularis, Pseudohypertrophic Paralysis) 

Under this heading are grouped the following four morbid condi- 
tions which were formerly looked upon as distinct pathologic en- 
tities : 

(a) Simple Hereditary Muscular Atrophy. It usually attacks 
children between eight and ten years of age, and is manifested by 
weakness and atrophy of the muscles of the back (without pseudo- 
hypertropl^), lordosis and paresis. 

(b) Infantile Muscular Atrophy (Facioscapulohumeral Type, Lan- 
douzy-Dejerine). — As the name indicates it begins in early infancy 
with atrophy of the face, especially the orbicularis oculorum and oris 
and the lips. The patient is unable to close the eyes, to point the 
mouth, and his face becomes expressionless, like a mask. Pseudo- 
hypertrophy of the facial muscles sets in later, so also the atrophy 
of the muscles of the scapulohumeral regions. 

(c) Juvenile Muscular Atrophy (Erb). — The atrophy is manifested, 
at a later age than in the former variety, in the following order: The 
pectorales, the anterior serrati, the latissimus dorsi, the rhomboidei, 
and the trapezius muscles, and then the triceps, biceps, brachioradial 
and brachial muscles. The deltoid is usually strongly hypertrophied. 

(d) Pseudohypertrophy (Duchenne). — In this form of the disease 
the muscles first affected are those of the calves, the extensors of the 
thighs which become greatly enlarged, and then the long spinal mus- 
cles. As the disease progresses the shoulder, arm and lumbar muscles 
become involved, the deltoid, supra- and infraspinati showing an 
especial tendency to pseudohypertrophy. The forearm and hands 
remain free. Owing to the weakness of the erector spinas and glutei 
muscles, the patient keeps his trunk thrown backward, "saddle- 
back," and walks with a peculiar waddling gait, with the legs widely 
separated and the toes barely touching the ground. The gait at times 
resembles that of bilateral dislocation of the hip. If placed on the 
floor, the efforts made to rise are very characteristic. Awkwardly 



660 



DISEASES OF CHILDREN 



and with difficulty he places first one hand and then the other on the 
legs, then on the thighs above the knees; and in this manner he 
"climbs upon himself" until he assumes the erect position (see Figs. 
191, 192, 193). In time, the patient becomes unable even to sit up. 

The distinction between the different forms of myogenic dystrophia 
cannot always be made with exactness, as the order with which 
atrophy begins is not rarely reversed. All varieties of the affection 
at a late stage present diminution of the tendon and electric reactions, 
but no reaction of degeneration or central disturbance. Fibrillary 




Fig. 191. Fig. 192. 

Figs. 191-193. — Pseudohypertrophic paralysis. Demonstration of mode of rising 
from the floor by ' ' climbing upon himself. ' ' 



twitching of the atrophied muscles is absent and local vasomotor dis- 
turbances are rare. As the disease advances and the paralyzed mus- 
cles contract, various deformities (spinal curvature, talipes, etc.) make 
their gradual appearance and render the patient totally helpless and 
bedridden. 

The course of the disease is slow, and occasionally interrupted by 
remissions of variable length, and temporary improvement. Death 
usually takes place within ten years from the onset of the affection, 
as a rule, from intercurrent diseases, especially pneumonia. 

Treatment. — The treatment in the form of baths, massage, etc., may 



DISEASES OF THE NERVE SYSTEM 



661 



prove effective to check the progress of the manifestations, but it is 
doubtful if it ever leads to permanent recovery. 

The disease is attributed to an extraordinary increase of connec- 
tive and adipose tissues with corresponding atrophy and gradual 




Fig. 193. 

disappearance of fibers of certain muscles. Slight lesions are hot 
rarely found also in the cord. The etiology is obscure. The absence 
of fibrillar twitching and of atrophy of the hands and forearms serves 
as differential points from "Spinal Progressive Muscular Atrophy." 
(See p. 658.) 

Lipodystrophia Progressiva 

Lipodystrophia progressiva is a term applied by Simons* to a syn- 
drome beginning most frequently between the fifth and twelfth years, 
and chiefly affecting females. In this condition, there occurs a grad- 

*A. Simons (Zeitschr. f. d. Ges. Neur. w. Psych., Berlin, 1911). 



662 DISEASES OF CHILDREN 

ual, progressive emaciation, beginning in the face, and progressing 
downward, involving the neck, shoulders, trunk and upper extremities 
and in most of the cases reported, an increased deposit of fat in the 
buttocks, thighs and sometimes the legs. The gradual disappearance 
of fat progresses until the appearance of the face is most character- 
istic. The cheeks become sunken, the eyes deeply set, the malar emi- 
nences prominent, and the temporal regions sunken. When the pa- 
tient smiles, the cheek is thrown into deep folds and the face generally 
has a cadaverous appearance. The neck becomes thin, the clavicles 
and scapulas extend prominently forward. The intercostal spaces 
are well marked; the breasts are pendulous and, owing to the disap- 
pearance of the fat, hard and nodular. 

In contrast to the wasted appearance of the upper extremities and 
face, the parts below the line of the iliac crests of the individual present 
a plump appearance; in some of the cases reported even amounting to 
grotesqueness. 

Usually, the attention of the family is first called to this condition 
by the emaciation which takes place in the face, and the fear of 
some acute disease prompts them to seek medical advice. The pa- 
tients themselves complain little or not at all. In advanced cases 
they sometimes complain of feeling chilly and of excessive perspi- 
ration or in other cases, of weakness or nervousness. 

In all cases there is a gradual progression of the emaciation of the 
face, upper extremities and trunk, and increase in size of the^ lower 
extremities over a period of ten to twenty years, after which there is 
spontaneous arrest. 

According to I. J. Spear (Archives, Int. Med., January, 1918) this 
condition is rather uncommon, only 24 cases having thus far been 
reported. 

Treatment. — Therapy seems of no avail. Paraffin injections have 
been recommended for corrective cosmetic purposes. 

Tumors of the Cord and Membranes 

Neoplasms of the cord are very rare and, hence, principally of 
pathologic and diagnostic interest. They may be primary (some 
times congenital) or secondary. Tubercle is the most frequent variety 
observed; next in frequency are gliomas, syphilomas, lipomas and 
sarcomas. 

The symptomatology depends upon the seat of the groAvth, essen- 
tially resembling that of myelitis, except that it is of gradual de- 
velopment. In benign unilateral tumors the symptoms (motor and 
sensory paralysis) are limited to the side affected. 



DISEASES OF THE NERVE SYSTEM 



663 



Treatment. — Antisyphilitic treatment deserves a full trial, and, if 
this fails, operative interference should be resorted to. 

Peripheral Facial Paralysis 

(Bell's Palsy) 

Facial paralysis may be due to trauma, pressure and irritation (swell- 
ing or disease) from contiguous structures (glands, teeth, ears) or ex- 
posure to cold or draughts. 

The symptomatology is essentially alike in all cases irrespective of 
cause. The paralysis is usually unilateral and effects the muscles of the 
forehead, the orbicularis oculi and some of the lower facial muscles. 
As a result, the paralyzed side of the face is lax and expressionless, the 




Fig. 194. — Peripheral facial palsy — Bell's palsy. Note inability to close right 
eye and to frown, as with the muscles of the left side of the forehead. Lower part 
of face unaffected. 

nasolabial fold more or less effaced; the eye remains widely open and 
the angle of the mouth droops. The paralysis becomes especially pro- 
nounced, when the muscles are thrown into action, e. g., on laughing or 
crying. In severe cases there is also paresis of the soft palate, and im- 
pairment of speech and mastication, and occasionally dulness of taste 
and diminished secretion of saliva. In otic facial palsy there may be 
disturbance of hearing (deafness; hyperacuteness). In the so-called 
rheumatic variety or that due to exposure, the onset is usually sudden 
and accompanied by neuralgic pain. The electric reaction remains nor- 
mal in mild cases, but is diminished or lost in grave cases. 



664 



DISEASES OF CHILDREN 



Prognosis and Treatment.— The prognosis and treatment depend upon 
the etiologic factors. Traumatic, especially obstetric facial palsy 
(q. v.), where the trauma is slight, usually ends favorably within a 
few weeks — without any therapeutic measures. 

Facial palsy arising from involvement of the facial nerve by aural 
suppurative processes (middle ear disease; caries of the petrous por- 
tion), usually runs a more protracted course, often long after the re- 
moval of the cause. Early attention to the ear affection is of vital 
importance. Cases resulting from dental caries can readily be remedied 
by treatment, possibly extraction of the diseased tooth. 

Rheumatic, grippal, etc., facial palsy ordinarily responds to local 
heat, the salicylates, quinine and arsenic. Pressure neuritis usually 
abates with disappearance of the swelling exerting the pressure upon 




Fig. 195. — Nuclear facial palsy. Eye muscles are unaffected; paralysis limited to 

lower part of face. 

the nerve. Facial palsy occurring in connection with parotitis calls for 
no special treatment. Where the pressure is due to a new growth, 
enucleation of the latter should be promptly undertaken. Eecovery is 
not as rapid in the latter form as in the other varieties. 

After abatement of the hyperacute symptoms, a weak galvanic cur- 
rent should be applied four to six times a week, for from two to three 
minutes at a time. The anode should be held behind the ear, while the 
different facial nerve branches and muscles are stroked with the cathode. 

It has been observed that recovery is assured — after a shorter or 
longer period of time — in all cases of facial paralysis in which the 
electric reaction remains normal after a lapse of from one to two weeks. 
On the other hand, cases which present complete reaction of degenera- 
tion of nerve and muscles after that period of time usually offer a doubt- 



DISEASES OF THE XERVE SYSTEM 665 

ful prognosis. Protracted cases may lead to degeneration and shortening 
of the affected muscles, so that the face appears drawn to the paralyzed 
side. 

Peripheral facial paralysis should not be mistaken for central or 
unclear facial palsy. In cerebral -palsy the muscles of the forehead and 
eyes, for the most part, escape (i. e., the patient is able to frown and to 
close the eye on the affected side) ; the electric reaction is retained; 
furthermore, the palsy is frequently associated with hemiplegia of the 
same side. In nuclear or basilar paralysis the palsy is usually limited 
to the lower half of the face (from the mouth down) and is complicated 
by other symptoms indicating a lesion in the pons, such as cross 
paralysis and disturbed action of other cranial nerves. 

Facial paralysis with lost electric reaction may often be mistaken for 
the permanent facial paralysis following acute poliomyelitis, (q. v.) 
Indeed, there is reason to believe that the so-called idiopathic form of 
facial paralysis which resists all methods of treatment is in reality of 
poliomyelitic origin. 

Hemlatrophia Faciei 

(Progressive Facial Hemiatrophy) 

The nature of this rare affection is still obscure. The pathologic 
findings point to an interstitial inflammatory process of the trigem- 
inus. It occurs in girls more frequently than in boys, on the left side 
more than on the right, and exceptionally affects both sides of the 
face. 

It begins with a small part of the face (usually over the fossa ca- 
nina) turning white, thin, wrinkled, etc. From here the atrophy 
rapidly spreads to the muscles and bones of the entire half of the 
face, including the hair. At times the atrophy spreads to the chest 
and other parts of the body, but finally reaches a permanently quies- 
cent stage. Sometimes there are also anomalies of pigment. It is 
occasionally associated with scleroderma and exophthalmic goiter. 
Sensation remains intact and the electric reactions are normal. 

Treatment.- — The cause of the atrophy being unknown, the treat- 
ment must, necessarily, be symptomatic. Paraffine injections have 
proved very useful to correct the remaining facial deformity. 

Polyneuritis 

(Multiple Neuritis) 

Polyneuritis is an inflammatory, degenerative affection of the periph- 
eral nerves. During the earlv stage onlv the sheaths of the nerves 



666 DISEASES OF CHILDREN 

are affected (hyperemia and the seat of minute hemorrhages). As the 
disease progresses we find connective tissue cells between the nerve 
sheaths, and red spindle-shaped cells between the nerve fibers, and also 
parenchymatous changes in the muscles. In severe cases the lesions 
ascend to the nerve trunks or even to the roots. Its distribution is al- 
most always bilateral and symmetrical. Polyneuritis is very rarely 
observed in children, since the principal causes of the affection— alcohol- 
ism, lead, and arsenic poisoning— are of exceptional occurrence in 
young children. The most frequent form of polyneuritis encountered is 
that described as "Diphtheritic Paresis' 7 (see Diphtheria), and on 
very rare occasions it is encountered also in connection with other 
infectious diseases. In one case under our observation (see Fig. 196) 
the pain and paresis set in six weeks after an attack of diphtheria. 





Fig. 196. — Diphtheritic polyneuritis in 
a boy four years old, affecting several 
groups of muscles of the neck, trunk and 
extremities. Note his inability to rise 
from the floor. 



Fig. 197. 
weeks later, 
rnent. 



-Same case as Fig. 196 two 
Note considerable improve- 



The paresis was very extensive and affected the muscles of the palate 
and throat (aphonia) neck, trunk, lower extremities and slightly the 
arms. The four-year-old boy recovered completely within about two 
months. Strychnine was the only remedy used. The neck was sup- 
ported by a felt collar. 

The onset of multiple neuritis is usually fairly rapid, with numbness, 
pricking, pain and chilliness of the parts affected. This is followed by 
the appearance of motor incoordination (ataxia, waddling gait) up to 
paralysis of symmetrical groups of muscles (e. g., of the hands and 
feet) or of entire extremities. The symptoms usually get gradually 



DISEASES OP THE NERVE SYSTEM 



667 



worse for about four weeks. The lower extremities are ordinarily af- 
fected first and the upper later. Genuine foot- and wrist-drop is rare. 
The same is true of involvement of the muscles of the trunk, and the 
sphincters. Exceptionally the diaphragm is affected. The motor symp- 
toms are usually associated with sensory disturbances — pain, especially 
on pressure, along the nerve trunks, hyperesthesia and more rarely 
anesthesia. The electric and tendon reactions are diminished, and re- 
action of degeneration is quite common in severe cases. 




Fig. 198. — Same case as Fig. 196 six weeks later. He is practically well, except for 
remaining weakness of the muscles of the neck. 

Treatment. — With early treatment — elimination of the poison 
(sodium iodide, magnesium sulphate, in lead poisoning), mitigation 
of pain (salicylates, warm baths), tonics (strychnine, iron, etc.), and 
galvanic electricity and massage, — the prognosis is usually favorable, 
except when the respiratory muscles are affected. In such cases com- 
plicating bronchopneumonia often ends fatally. Occasionally atrophy, 
with consecutive contractures and deformities, may persist for a long 
time, and even for life. 



C68 



DISEASES OF CHILDREN 



Differential Diagnoses 





POLYNEURITIS 


POLIOMYELITIS 


LANDRY'S DISEASE 


Onset 


Usually slow. Slight 


Quite acute; often 


Slight prodromata 




fever, if any 


vomiting. Moder- 
ate fever 


(pain) ; no fever 


Distribution of 


Symmetrical. Par- 


Irregular. Complete ; 


At first asymmetrical. 


paralysis .... 


tial. Lower, then 


often only one 


Ascending. Com- 




upper extremities. 


limb, or a group of 


plete. Legs, trunk, 




Exceptionally other 


muscles, e.g., shoul- 


arms, and muscles 




parts of body 


der or face. 


innervated from the 
medulla 


Hyperesthesia . . 


Persistent 


Transient 


Variable 


Anesthesia 


Present (partial) 


Absent 


Absent 


Atrophv and de- 


Late and slight 


Early 


Very late, if at all 


formities .... 








Termination . . . 


As a rule, gradual 


Partial, spontaneous, 


Usually fatal within 




recovery 


recovery 


two weeks. Excep- 
tionally, recovery 



The history of the case is very helpful in the diagnosis. Thus, in 
multiple neuritis, we are often able to elicit a history of some form 
of toxemia (infectious disease, especially diphtheria, lead, arsenic, or 
alcohol poisoning) ; in poliomyelitis its prevalence in epidemic form 
may be decisive. 

Polyneuritis may occasionally be mistaken for hereditary ataxia — 
very slow in development, involvement of cranial nerves, and mental 
debility; and myelitis — sphincters invariably involved. 



B. FUNCTIONAL DISEASES 

Spasmophilia 

(Eclampsia Infantum, Tetanism, Tetany, Pseudotetanus, 
Spasmus Glottidis) 

The subject in epiestion is of great clinical interest, and still shrouded 
in mystery. Spasmodic affections are generally attributed to a number 
of local bodily irritations which act reflexly upon the central nerve 
system. We know also that the infantile brain is very vascular, very 
irritable, very impressionable, lacking in power of resistance and con- 
trol. "We are in the dark, however, as to why the very same etiologic 
factors are prone to produce mild or severe convulsions in one child 
and none at all in the other. This apparent discrepancy in action leads 
one to assume that some children are born with a marked (familial?) 
tendency to spasmodic affections. This, probably hereditary, spasmodic 
tendency ("spasmophilia") is distinctly traceable in children of nerv- 
ous, alcoholic, syphilitic or tuberculous parentage, and exerts its influ- 
ence principally on the group of functional spasmodic affections pres- 
ently to be described. 



DISEASES OF THE NERVE SYSTEM 669 

I. Eclampsia Infantum 
(Convulsions) 

Nonepileptic convulsions are of common occurrence in children, es- 
pecially in infants under one year of age and are the immediate result 
of an irritation of the centers in the pontobulbar junction or in the area 
of Rolando, superinduced either by cerebral anemia or hyperemia. 
They may occur as a partial, often initial phenomenon of all sorts of 
acnte systemic disturbances, e. g., toxemia from infectious diseases; 
gastrointestinal intoxication ; shock, and trauma ■ or in consequence of 
continued reflex irritations, such as phimosis, adenoids, intestinal 
worms, intense pain from various causes, earache, difficult teething. 
calculi, and the like. In quite a number of children, a rise of tempera- 
ture from whatever cause will produce intense convulsions and will 
continue to recur until the temperature has been reduced. The fre- 
quency of the convulsive seizures is within no definite limits — from one 
attack in several months up to as many as thirty or more attacks in a 
day. In mild cases the convulsions may be manifested merely by twitch- 
ing of the lips or eyelids, etc. ; in severe cases, however, the convulsions 
are both tonic and clonic in character. In the beginning, the body is 
more or less rigid, the head and neck are retracted, the eyeballs are 
turned upward or roll spasmodically in different directions. The face 
is distorted and grows cyanotic as breathing becomes labored or tem- 
porarily ceases. These tonic spasms are soon replaced by clonic convul- 
sions — irregular and rapid twitching of the extremities and face or of 
single groups of muscles — which may last from a few seconds to several 
minutes, may remit, and return with greater violence. With complete 
cessation of the convulsions the patient usually falls asleep, to wake 
up apparently free from cerebral disturbance. During the attack con- 
sciousness is lost. Occasionally, there may be loss of sensation as well 
as involuntary urination and defecation, foaming from the mouth and 
biting of the tongue — a group of symptoms which is generally met in 
epilepsy. This, together with the fact that eclampsia is not rarely a 
precursor of genuine epilepsy, should put the physician on his guard 
in venturing a positive view as to the nature and curability of the 
spasmodic affection. 

Epilepsy differs from infantile eclampsia in that the fit is preceded 
by an aura, that it is of short duration but nonremittent, and that it 
is invariably followed by profound sleep — not the light sleep which 
follows eclampsia. We should bear in mind, however, that these dif- 
ferential signs are much less reliable in epilepsy of children than in 
adults. 



G70 DISEASES OP CHILDREN 

Eclampsia infantum is to be carefully distinguished from uremic 
convulsions, and spasms accompanying brain disease. In uremia 
there is usually a history (scarlatina?) of suppression of urine. The 
latter reveals evidences of kidney disease. Cerebral convulsions are 
associated with projectile vomiting, possibly a history of trauma, tuber- 
culosis, otic abscess, and the like. The convulsions of organic brain 
disease (tumor or abscess) are apt to be more localized and be followed 
by paralytic phenomena. 

Treatment. — When called upon to treat a child in an attack of 
convulsions, the physician is rarely in position to make exact and 
scientific discriminations between the different forms of convulsions. 
It is essential to arrest the convulsions irrespective of cause or effect, 
since a prolonged attack may end fatally from exhaustion or suffoca- 
tion. The spasms are best controlled by means of chloroform inhaled 
from a loosely applied handkerchief, moistened with % to 1 teaspoon- 
ful of the anesthetic. In this manner the anesthetic may be contin- 
ued, at long intervals, for hours or days without endangering the life 
of the patient. As the convulsions subside, we begin to make careful 
inquiry into their causation and to employ the therapeutic measures 
indicated in each individual case. Hyperpyrexia calls for hydro- 
therapy (cold sponge or tub bath); gastroenteric disorders, for emesis 
(apomorphine 1/16 grain hypodermatically, or ipecac by mouth), 
catharsis (2 grains of calomel in one dose), and enteroclysis; intestinal 
worms, for teniafuges (turpentine inhalation, and calomel -.and san- 
tonine by mouth) ; nervous disturbances, for hot baths with or without 
mustard, bromide and chloral per rectum or by mouth, and counter- 
irritation in the form of a mustard plaster or mustard-water cloths 
applied to the spine from the nucha downward. Lumbar puncture is 
a sovereign remedy in all forms of cerebral irritation associated with 
increased intracranial or intraspinal pressure and with the usual pre- 
cautions can safely be employed in convulsions failing to yield to 
milder procedures. 

With cessation of the convulsions due attention should also be paid 
to the more remote etiologic factors, principally with the view of 
prophylaxis. The diet should be regulated, the general health im- 
proved, rachitis promptly attended to, faulty environment amelio- 
rated, local irritations (e. g., phimosis, adenoids, foreign bodies in the 
ear or nose, rectal fissures, stomatitis, intense itching, etc.) promptly 
removed, and all such therapeutic measures instituted as will help to 
counteract and eradicate the inherent tendency to spasmodic affections. 

Occasionally convulsions in children are met which recur for 
several years irrespective of all prophylactic and therapeutic meas- 



DISEASES OP THE NERVE SYSTEM 



671 



ures, and then suddenly cease. In such cases the cause will probably 
be found in some obscure disturbance of the endocrine glands, giving 
rise to some form of autointoxication. 



I* 



Natrii Bromidi 3 i 




4.00 


Antipyrinae 3 ss 




2.00 


Tr. Ammonii Valerianatis 3 ii 




8.00 


Syr. Laetucarii 3 iv 




15.00 


Aq. Aurantii Flor. q. s. ad f § ii 




60.00 


M. 




S, — One tea spoonful every three to 


six hours, 


for a child two years old. (General 


nerve se- 


dative.) 







II. Tetanism 

This term is intended to denote a peculiar form of continued mus- 
cular hypertonicity occasionally observed in very young infants with 
markedly lowered vitality, be it as a result of prematurity, syphilis or 





Fig. 199. — Tetanism during acme of Fig. 200. — Tetanism. Same case as 

spasm. Note characteristic position of Fig. 199 during partial relaxation of 
the extremities. spasm. 



672 



DISEASES OF CHILDREN 



chronic gastroenteritis. The onset of the spasticity is fairly rapid, 
and in severe cases, when fully established, the posture assumed by 
the patient is pathognomonic (Fig. 199). The head is moderately re- 
tracted, the facial muscles are contracted, the jaws are firmly set 
together, the forearms are flexed upon the arms and the hands are 
tightly clenched, so as to form firmly closed fists. As a rule, the legs 
are bent angularly and the feet either overlap each other or are 
arched. The muscular contractures relax off and on (Fig. 200), more 
especially during profound sleep, but never subside entirely. The 
hypertonicity increases on handling the baby, but it never interferes 
with feeding. With improvement of the general health of the baby, 
the contractures disappear. 

As may be noted from the accompanying illustrations, tetanism is 
a t} T pical clinical picture easily to be differentiated from similar spas- 
modic affections. On the first examination of the patient we may sus- 




Fig. 201.— Same case as Fig. 199 three months later. 

pect either tetany, tetanus, or eclampsia, but on careful analysis of the 
symptomatology of the affections, the erroneous impression can read- 
ily be dispelled. Tetanism differs from tetany by its more gradual de- 
velopment and almost continuous persistence for several months; any 
kind of handling of the baby increases its muscular hypertonicity, 
while in tetany the attacks may be brought about or aggravated only 
by pressure upon large trunks of nerves or arteries (Trousseau's 
phenomenon), electric excitability (Erb's phenomenon), or irritation 
of the facial nerve (Chvostek's sign). Tetanus is an acute disease, 
preceded by an infection, as a rule accompanied by difficult degluti- 
tion and respiratory embarrassment and usually ending fatally within 
a week. Eclampsia infantum occurs in attacks and is associated with 
loss of consciousness. In the same manner we can promptly exclude 



DISEASES OF THE NERVE SYSTEM 673 

so-called meningismus; moreover, none of these spasmodic affections 
of infancy ever give rise to the characteristic contractures of the ex- 
tremities just described. 

With improvement in the general condition, the spasticity gradu- 
ally (within a week or a month or longer) subsides. Few babies in 
that dilapidated state survive, however, the persistent gastroenteritis 
and increasing exhaustion. 

Treatment. — Prophylaxis and therapy the same as in tetany (q. v.) 
except that there is no indication for the employment of hypnotics. 

III. Tetany 

This disease is characterized by intermittent, somewhat painful, 
contraction of certain groups of muscles, especially of the extremities, 
with exaggeration of the mechanical and electric irritability. The 
spasm is bilateral and usually sets in abruptly without loss of con- 
sciousness. The hands assume a very peculiar shape greatly re- 
sembling that of holding a pen or of making a strenuous effort to 
restrain a spirited horse. Thus, the arms are pressed against the 
chest, the hands are bent on the forearms, the fingers are flexed upon 
the palms, the phalanges are extended, the thumbs are turned inward, 
so as to be covered by the other fingers, and the wrists are flexed in 
pronation. "When the lower extremities are affected, the legs are 
adducted and the plantar surfaces of the feet are strongly arched, 
with a tendency to an equino varus position. Occasionally the tetanic 
spasm extends to the neck and back, and exceptionally also to the 
laryngeal and other muscles of the body. On the other hand, cases 
of tetany are encountered in which the spasms are entirely wanting 
or barely indicated. These " latent" or passive forms of tetany may 
frequently be brought into activity by energetic pressure upon the 
main trunks of the nerves or vessels (e. g., bend of elbow). This pe- 
culiar mechanical manifestation is spoken of as "Trousseau's phenome- 
non," and forms one of the three positive signs of tetany — the so-called 
"triad of tetany." The other two signs of tetany are those of Chvostek 
and Erb. " Chvostek 's phenomenon" is based upon exaggeration of the 
mechanical irritability of the motor nerves, especially of the face (fa- 
cialis phenomenon), and consists of lightning-like contractions of the 
face superinduced by percussion (with the finger or hammer) over a 
branch of the facial nerve while the face is in a state of perfect rest. 
"Erb's phenomenon" is based upon electric excitability of the motor 
nerves and muscles, and Escherich and von Pirquet maintain that we 
have not only a reaction or muscular response to local cathodal opening 
and closure, but that a current of 4 ma. is sufficient to produce muscular 



G74 



DISEASES OP CHILDREN 



contraction or anodal closure and opening as well "anodal suscepti- 
bility." 

The duration of the tetanic attack varies from a few minutes to 
several hours or longer. When they have lasted some time there usually 
develops edema of the dorsi of the hands and feet. The spasms may 
recur once or several times daily or but once in several days. In the 
great majority of cases the disease usually subsides within a few days 
or a month or two, without any permanent sequelae, provided suitable 
treatment is instituted early. Zonular cataract may occasionally form 
a sequel of tetany and is probably due to the effects of faulty metabolism. 










202. — Tetany in a child eleven months old. 

hands and feet. 



Note characteristic attitude of 



Whether or not the immediate cause rests upon functional or or- 
ganic disturbance of the thyroid glands or parathyroids (hemorrhage 
in the epithelial bodies) is still subject to great differences of opinion. 
Escherich and his pupils strongly favor this theory and endeavor to 
prove that the faulty distribution of calcium was due to interference 



DISEASES OF THE NERVE SYSTEM 675 

with the functions of the parathyroid. Howland and Marriott* insist 
that enough studies have been made to show that parathyroid lesions 
in infancy are the exception and not the rule. Furthermore, they 
maintain that parathyroid lesions as severe as have been found after 
tetany may occur in patients who, during life, have shown absolutely 
no evidences of this symptom. Their conception of tetany is that 
some factor, at present unknown, causes a reduction of the calcium 
content of the blood. "When this drops to an amount roughly between 
6 and 7 mg. of calcium per hundred c.c. of serum, frank evidences of 
tetany arise. This amount, however, is not the same with all individ- 
uals. With some it may be as low as 5.5 or 6, with others as high as 
7.5. These symptoms occur in outbursts so long as the calcium re- 
mains low. When the calcium rises, the symptoms disappear. The 
height to which the calcium must rise in order that the symptoms 
must disappear is also somewhat variable. Wilson 1 and his co-workers 
at the Johns Hopkins Medical School found that, following parathy- 
roidectomy in dogs, the equilibrium between acids and bases is dis- 
placed in favor of the bases, and that in tetany developing after 
such a procedure there is well marked alkalosis. The results have 
been confirmed by McCann 2 at the Harvard Medical School, who 
agrees that there is a marked increase in the carbon dioxid-combining 
power of the blood plasma, coincident with the development of tetany. 

Treatment. — The treatment, especially with the view of prophylaxis, 
is essentially the same as employed in rachitis — corresponding to the 
apparent relationship that exists between the pathogenesis of rickets 
and that of tetany. Similar to rickets, tetany occurs in infants chiefly 
of a half to two years of age. Like rickets tetany shows a predilection 
for poorly fed and poorly housed children, and, finally, as in rickets, 
the immediate cause of tetany seems to be some form of intoxication, 
intestinal or otherwise. 

The diet should be regulated, as to quality and quantity. 
Young infants should, if possible, receive breast milk. The in- 
testinal tract should be cleansed with calomel by mouth, lavage 
and low enemas. For the relief of severe contractions prolonged 
warm baths, bromides and chloral will usually prove efficient (see 
"Rachitis") ; and in view of the fact that there is an insufficiency 
of calcium in the blood and also that in surgical parathyreopriva 
calcium is found to arrest the tetanic spasm, we are fully justi- 



*Howland, John, and Marriott, W. McK. ; Observations on the Calcium Content of the 
Blood in Infantile Tetany and on the Effect of Treatment with Calcium. (Bull. Johns Hos- 
kins Hosp., Vol. xxiv, p. 235. 1918). 

a Wilson, D. W.; Stearns, Thornton, and Janney, J. H., Jr.; T. Biol. Chem. 21, 169, 1915; 
Wilson, D. W.; Stearns, Thornton, and Thurlow, M. D. : . Ibid. 23, 89, 1915. 

2 McCann, W. S.: A Study of the Carbon Dioxide-Combining Power of the Blood Plasma in 
Experimental Tetany, J. Biol. Chem. 35, 553 (Sept.) 1918. 



676 DISEASES OF CHILDREN 

lied in favoring its administration also in infantile tetany. Syr. 
calcii lactophosphatis (% dram) or calcium lactatis (2 grains) three 
times daily are useful preparations. Phosphorus with cod liver oil 
should be given a fair trial. 

Late or Puerile Tetany is met with in children over three years, and 
is manifested chiefly by carpopedal spasm of brief duration. 

IV. Pseudotetanus* (Escherich) 

This affection differs from tetanus principally by its predilection for 
the muscles of the trunk, and its afebrile course; from tetany by its 
spasticity being continuous, and from tetanism by the fact that it at- 
tacks children of from four to fourteen years of age (instead of in- 
fants) who are apparently enjoying perfect health. The pathogenesis 
of the disease is still unknown. 

The patients (usually boys) suddenly complain of stiffness in the 
legs and inability to walk about. The rigidity rapidly extends to 




Fig. 203. — Pseudotetanus. (After Pfaundler and Schlossmann.) 

the back and head, so that the patient lies motionless like a log, ex- 
cept for his ability to make free use of his arms and hands. The 
affected muscles are maximally contracted, prominent, and as hard as 
marble. The facial muscles except those of the eyes also are in a 
state of tonic spasm, so that the facial expression is that of trismus, 
the teeth are firmly set together and barely separable with force. 
Nevertheless, there is but little difficulty in feeding the patient. The 
rigidity is in partial abeyance during sleep as well as during perfect 
rest, but greatly increased — up to painful opisthotonos, spasm of the 
diaphragm, etc. — by all sorts of bodily or mental irritations. During 
the height of the disease such spasmodic paroxysms may occur also 
spontaneously several times a day and are usually followed by pro- 
fuse sweating. 



*There is considerable diversity of opinion regarding the existence of such a clinical entity. 
It surely is of very rare occurrence. 



DISEASES OF THE NERVE SYSTEM 677 

The spasmodic condition persists without apparent variation for 
from three to six weeks, whereupon the contractures gradually (within 
from two to four weeks) abate never to return. 

Treatment. — The treatment is symptomatic. (See "Tetany".) Ga- 
vage, if necessary. 

V. Spasmus Glottidis 

( L ARYNGOSPASM ) 

Spasm of the glottis is a disease of infants of from six to twenty-four 
months old, the age in which rickets is most apt to prevail. It is closely 
related to and a frequent partial phenomenon of tetany (usually shows 
Trousseau's and Erb's signs) and seems also to rest upon the identical 
pathogenesis of the latter disorder. 

The spasmodic attack is manifested by sudden deep inspiration, 
dyspnea, apnea, pallor and later cyanosis of the face, fixation or rolling 
of the eyes, and more or less marked rigidity of the body. At the end 
of a few seconds breathing is resumed after a noisy expiration. In 
severe cases the spasm not rarely extends to the diaphragm and to the 
entire musculature of the body. 

The attacks usually recur at shorter or longer intervals (several 
times a day!), and, if not terminating fatally, which may occasionally 
take place very suddenly even during a simple attack as a result of as- 
phyxia, they gradually subside after a few weeks or months. In mild 
cases recovery is the rule. The physician should be guarded, however, 
in the prognosis. 

Spasmus glottidis can readily be distinguished from other forms of 
laryngeal stenosis (e. g., retropharyngeal abscess) by its intermittency 
and noiselessness, between each attack. It should not be confounded 
with the momentary apnea ("holding the breath"), frequently ob- 
served in children during a fit of crying. (See "Congenital Stridor" 
and "Thymus Hypertrophy".) 

Treatment. — As the physician rarely has the opportunity to witness 
an attack of laryngospasm, his efforts must be directed chiefly toward 
its prevention. This is best accomplished by antirachitic treatment 
(q. v.), including calcium, careful attention to the alimentary tract, and 
calming of the irritability by means of small doses of sodium bromide. 
(See "Eclampsia".) Severe attacks call for stronger hypnotics. 

A severe attack may sometimes be aborted by dashing cold water in 
the child's face, exciting choking motions by pressure upon the root of 
the tongue, and exciting sneezing by irritating the nasal mucous mem- 
brane. In some cases light ethyl chloride or ethyl bromide anesthesia 



678 DISEASES OF CHILDREN 

may be tried. Timely intubation and artificial respiration have saved 
some babies from immediate death. 

Chorea Vera 
(St. Vitus 's Dance, Chorea Minor, Sydenham's Chorea) 

Genuine chorea is an acute, infectious, sporadic and epidemic affec- 
tion characterized by spontaneous, irregular movements of the vol- 
untary musculature, and by a special tendency toward cardiac com- 
plications. 

The specific causal microorganism of this disease is still unknown, 
but is probably closely related to that of rheumatic affections, with 
which chorea is occasionally associated. Other infectious diseases 
(such as exanthemata), fright and mental overwork serve as predis- 
posing causes. 

The onset of chorea is preceded by prodromata varying in duration 
from a few hours to a few days. They consist of fretfulness, fatigue, 
pain in the extremities, restless sleep and occasional twitching. After 
the prodromic stage the actual attack may be precipitated abruptly 
and with full force, or come on gradually and run a mild course. The 
cardinal symptoms of the disease are irregular, awkward, involuntary, 
muscular movements — hasty and beyond control — which cease only 
during sound sleep. The movements intermittently involve various 
sets of muscles never letting up a moment while the patient is awake. 
The movements are intensified when the patient is conscious of being 
observed, and tries to control them, or attempts to perform some 
voluntary action. The shoulders, one or both, jerk upward or down- 
ward, the arms rotate from side to side, or are forcibly thrown back- 
ward, the hands are engaged in incomplete extension, flexion, prona- 
tion or supination, while the fingers are bent, extended or shoved 
one over the other so that the patient is unable to hold an object 
firmly, to write, to button a garment, etc. The head sways from side 
to side, often describing a semicircle, or is dropped downward so that 
the chin touches the chest wall. The facial muscles twitch, and pro- 
duce grotesque distortions of the face and mouth. The forehead is 
wrinkled, the eyes open and close, the patient seeming to cry or laugh. 
In one case under our observation the iris ( ! ) was involved so that 
the pupils contracted and dilated almost incessantly. The tongue 
participates in the movements, causing difficulty in eating and drink- 
ing, and defective speech up to aphasia. The movements of the lower 
extremities vary with the intensity of the attack, in severe cases be- 



DISEASES OF THE NERVE SYSTEM 679 

nig of such nature that the patient is unable to stand, sit or lie still, and 
frequently falls, stumbles, or is thrown out of bed and injured. Dur- 
ing- the acme of the attack it is not uncommon to find irregular res- 
piration and arrhythmia of the pulse — both from implication of the 
respiratory muscles and the heart {chorea cordis). However, notwith- 
standing the intensity of the movements the patients rarely complain 
of being fatigued, in fact a great many children seem otherwise in per- 
fect health. The temperature is normal, the digestion good, sensory 
disturbances are usually rare and slight (hyperesthesia along the course 
of the nerve trunks), the patellar reflex is somewhat exaggerated, but 
the cutaneous sensibility and reflexes are unaltered. 

If left untreated the active stage of the disease lasts from four to six 
weeks; then the symptoms gradually diminish and may disappear en- 
tirely a few weeks later. Some cases run a mild course from beginning 
to the end, at no time presenting the aforementioned grotesque muscular 
excursions. This is especially prone to occur if treatment is begun 
early, and persisted in. 

The intensity of the attack stands in no relation to its duration; on 
the contrary, cases of slow development and moderate severity may 
run a chronic course and suffer relapses, while violent cases often 
respond to a few weeks' treatment, This incongruity is often ob- 
served also as regards complications ; mild cases being not rarely 
associated with fever, inflammation of the joints, pleura, pericardium 
or endocardium, whereas severe chorea may run its course without 
any untoward results. In reference to heart complications which is 
supposed to occur in about 20 per cent of cases, it is well to remember 
that not every blowing heart sound heard in chorea is indicative of 
valvular lesion; the majority of these adventitious sounds, especially 
those heard at the base, disappear, perhaps, never to return. On the 
other hand, heart lesions have been found at the autopsy without any 
indications of their presence during life, a fact which strongly em- 
phasizes the necessity of prophylactic measures (perfect rest) being 
taken against heart disease during the active stage of the disease. 

Sometimes the muscular disturbance is limited to one-half of the 
body (Jiemichorea) , showing that the lesion is localized in one hemi- 
sphere of the brain. This form of chorea is more serious than bilateral 
chorea. It is often associated with paresis of the extremities, one or 
both (chorea paralytica; chorea mollis), and changes in the psychical 
condition, e. g., melancholy, hallucinations. 

Notwithstanding the grave nature of the affection, the prognosis of 
chorea, on the whole, is favorable. A fatal termination is exceptional. 



G80 DISEASES OF CHILDREN 

This may occur either as a result of complicating' heart disease, or from 
some, as yet unknown, effect upon the central nerve system. To the 
latter class belong the cases associated with delirium and prostration 
(chorea insaniens). On the other hand, the prognosis as to permanent 
recovery is not quite promising. Recurrences are frequent, and as pre- 
viously mentioned, the tendency to permanent heart disease is great. 

Treatment. — With these facts in view, the urgency of instituting 
preventive measures against chorea is obvious. This is strongly em- 
phasized by the observation that chorea ma}- appear in epidemic form 
(it is quite common to find several members of one family to be at- 
tacked simultaneously or within a brief period of time). I am not 
referring to the hysterical "pseudochorea" not rarely encountered in 
epidemic form in girls' boarding schools. (See "Hysteria".) Pro- 
phylaxis is best accomplished by isolation of the patient. This is 
imperative in hospitals, asylums or private schools where several 
inmates are congregated in close quarters. Girls, between six and 
twelve years of age particularly, should be kept apart, as they are 
very susceptible to chorea: about 70 per cent of the cases are met 
in girls, probably because of their poorly developed body musculature. 
In recurrent chorea the teeth, tonsils and adenoids should be looked after. 

The active treatment consists principally of perfect rest in bed in 
an airy and sunny room, and avoidance of all mental excitement. 
While the choreic movements are very pronounced, the patient should 
be kept in a well-padded bed (to avoid injury) day and night, but, as 
the symptoms improve, she may be allowed to sit up or be around and 
about for a few hours at a time. A warm bath with a cool sponge 
once or twice a day and a daily colon flushing are very salubrious. 
The food should be bland, nutritious, and preferably liquid or semi- 
solid (milk, cereals, broths, fruit juice, etc.), especially when mastica- 
tion and degulutition are difficult. Arsenic in the form of Fowler's 
solution is the remedy par excellence in all cases of chorea, except when 
associated with marked paresis. It should be begun with in 14 drop 
doses for every year of the child's age, and increased by V2 a drop 
every other day. Should the urine show the presence of albumin, 
the lids become puffy, the stomach irritated (pain or nausea), it is 
advisable to go back to the original dose, or to discontinue it entirely 
for a few days. In the so-called paralytic cases the cacodylates of 
arsenic, strychnine and glycerophosphates, administered either by 
mouth or, preferably, hypodermically, often act exceedingly well. 
Whenever sore throat or rheumatic pain has preceded the attack of 
chorea, the salicylates, with or without digitalis, should be pushed to 
full tolerance. During the acme of the disease, the bromides, and 



DISEASES OF THE NERVE SYSTEM 681 

more powerful hypnotics, if needed, will be found to act kindly in re- 
ducing the severity of the choreic movements, allaying the nerve irri- 
tability and inducing sleep — all of which being essential to the recovery 
and maintenance of the strength of the patient. In very grave cases 
chloroform anesthesia may very cautiously be resorted to. Many 
years ago I reported a number of cases of protracted chorea which 
were greatly benefited by lumbar puncture. The suggestion recently 
made to inject an autogenous blood serum into the spinal canal has 
failed to meet with favor. The same holds true for the intraspinal 
injection of magnesium sulphate. Finally it is well to bear in mind 
that a number of cases will run their course, uninfluenced by any 
method of treatment, and possibly be harmed by overtreatment. In 
refractory cases we may try a milk- and meat-free diet, for a week 
or two. 

B; Liq. Potassii Arseuitis 

Aq. Aurantii Flor. aa 3 ii 8.00 

M. 

S. — Begin with one drop for every year of the 
child's age and increase by one drop every other 
day, up to full tolerance. To be well diluted in 
water. 



Xatrii Salicyl 




Xatrii Bromidi aa 3 i ss 


6.00 


Mist. Ehei et Sodae 3iv 


15.00 


Aq. Destil. q. s. ad f 5 ii 


60.00 


M. 


S. — One teaspoor>ful every four to six hours, 


for a child six years old. 


Ferri Sulph. Exs. gr. x 


0.60 


Pulv. Chocolate oi 


4.00 


M. Div. in pulv. no. xx. 


S. — One powder after each meal. 





^ 



Habit Spasm 

(Tic) 

Children of a nervous temperament quite frequently acquire the 
habit of spasmodically moving the head (swaying, rolling or nod- 
ding), face (tic), fingers and hands, which, if not immediately stopped 
by strict discipline, is apt to persist for weeks and months. In some 
cases the bad habit is traceable to faulty wearing apparel. For ex- 
ample, head nodding in girls from poorly fitting hats, head swaying 
in boys from a too tightly fitting collar, etc. Habit spasm should not 
be confounded with chorea. 



682 DISEASES OF CHILDREN 

A similar spasmodic condition has been described by Henoch as 
"chorea electrica." It occurs in children from nine to fifteen years 
old, in the form of lightning-like spasms, especially of the neck and 
shoulders, as though produced by a galvanic current. This spasm 
seems to be identical with "paramyoclonus multiplex" (a neurosis 
marked by shock-like muscular contractions, which are bilateral and 
do not, as a rule, affect the hands and face) but may be hysterical 
in nature. Electricity does well in these cases, probably by suggestion. 

Spasmus Nutans 

(Spasmus Kotatorius, Head Nodding) 

The disease in question is of obscure origin. It is usually seen in 
infants of from four to eighteen months of age, chiefly in those suffer- 
ing from rachitis. The spasmodic movements are generally limited to 
the muscles innervated by the cervical plexus and the accessory nerve, 
notably the recti capitis, longus colli, scaleni and sternocleidomastoid. 
In consequence of the irritation, the head rotates from side to side or 
shakes anteroposteriorly at a variably rapid (every second) pace, 
with occasional interruption, but ceases entirely only during sleep or 
temporarily while blindfolded (Caille). The head nodding is usually 
associated with nystagmus and more rarely strabismus or rolling of 
the eyeballs. In some cases some etiologic relation seems to exist be- 
tween spasmus nutans and visual disturbance, but whether the defect 
be in the muscle or nerve supply is still a matter of conjecture. 
Henoch attributes the association of the nystagmus with the rotatory 
movements of the head to the close proximity of and extension of irri- 
tation from the ocular nuclei to the nuclei of the nerves and muscles 
which rotate the head. 

The spasmodic movements gradually disappear in the course of a 
few weeks or months, after improvement in the general health. (See 
Rachitis.) 

Spasmus nutans may be confounded with "juvenile congenital 
nystagmus" (associated with marked visual defects, e.g., disease of 
the retina, lens, etc.) ; with brain disease which can readily be recog- 
nized by the concomitant symptoms, and with "epilepsia nutans" (q.v.). 

Hysteria 

Hysteria is a neuropsychosis, a product of faulty environment and 
education.* It is rare in children under eight years of age, but quite 
common in older ones, especially in girls. 



"Sheffield, H. B : A Contribution to the Study of Hysteria in Children. (New York Med. 
Jour., September 17 and 24, 1898.) 



DISEASES OF THE NERVE SYSTEM 683 

The onset of hysteria can frequently be traced to some sudden vio- 
lent emotion (shock) with, or more rarely, without bodily injury. 
The attendant circumstances at the time of the psychic disturbance 
often serve to determine the seat of the hysterical lesion, e. g., hysteri- 
cal deafness after an explosion, paralysis or contracture of an extremity, 
after a trivial injury. 

The symptomatology of hysteria is characteristic for its multiplicity 
and mutability. It may closely simulate that of any organic disease, 
but its spuriousness can usually be detected after careful scrutiny. 
The diagnostic perplexities augment, however, with accidental con- 
currence of some acute affection or preexistence of a chronic organic 
disease. 

Paralysis of the extremities with or without contracture forms a 
frequent hysterical manifestation. It may appear in the form of para- 
plegia, monoplegia, or hemiplegia, and thus resemble myelitis, polio- 
myelitis, or cerebral paralysis. In hysterical "spinal" paralysis, how- 
ever, there is rarely absolute loss of muscular power. Muscular 
atrophy is absent or slight, and electric irritability remains normal. 
In hysterical "cerebral" paralysis, also, the loss of power is rarely 
complete and the leg is often more affected than the arm. The face 
usually remains uninvolved. A peculiar form of either continuous or 
intermittent pseudoparalysis is occasionally met with in children, 
which has been described by Blocq as "astasia-abasia." In this con- 
dition the muscles of the lower extremities can be freely used except 
in standing or walking. If the latter is attempted, the patient im- 
mediately falls to the ground or begins to tremble and topples over, 
or manifests ataxic sympoms (cerebellar type). The difficulty in 
walking is sometimes overcome after a few steps are taken. 

The hysterical contractures may involve the articulations, groups 
of muscles or a part of a muscle. As a rule, the joints of the tapering 
extremities are most frequently affected. All sorts of deformities 
may arise which may greatly resemble genuine joint and bone dis- 
ease (e. g., hip-joint disease, spondylitis, talipes, etc.) and lead to 
errors in the diagnosis. The more sudden onset, the irregularity of 
its course, the tendency to change its situation and the concomitance 
of other evidences of hysteria, all help the exclusion of organic disease. 
At a later stage the diagnosis of hysterical contracture can frequently 
be made by the absence of local thickening, or active inflammation of 
the bone or muscle and its disappearance under anesthesia. Where 
part of a muscle is affected the contracture may give rise to circum- 
scribed swellings. Allied in nature are also the so-called "phantom 
tumors" occasionally observed on the lower portion of the abdomen, 



684 



DISEASES OF CHILDREN 



and the peculiar "ballooning" of the hypogastrium manifested with 
each expiration. Occasionally the abdominal enlargement is general 
and not rarely accompanied by local tenderness. Furthermore, the 
hysterical tympanites may be associated with vomiting, anorexia, 
singultus, disturbed respiration, retention of urine, etc., and thus give 
rise to the clinical picture of peritonitis, which may test the skill of 
even the best diagnostician. As a rule, obstipation and fever are ab- 




Fig. 204. — Hysterical phantom tumor of the abdomen. 

Schlossmann.) 



(After Pfaundler and 



sent in these cases and the vomiting is not so persistent as in true peri- 
tonitis. Of course, vomiting, anorexia, tachypnea, etc., may exist 
independently of the hysteria and greatly obscure the diagnosis. 

The symptoms thus far enumerated represent principally the neu- 
rotic element of hysteria. To those may be added the occasionally 



DISEASES OF THE NERVE SYSTEM 685 

occurring cataleptic states, spasms of the laryngeal muscles (croup), 
dysphagia, aphasia, aphonia, with spells of coughing, singing, or stut- 
ering, asthma, amblyopia, hemianopsia, contraction of the visual field, 
amaurosis, and blepharospasm. 

In another group of cases the psychic element predominates. Here, 
too, however, there is generally a great display of spasmodic and con- 
vulsive movements ranging between simple or choreic tremor to 
marked epileptiform convulsions (hysteroepilepsy). The movements 
may assume the form of athletic exercises, such as rowing, swimming, 
punching, etc. — chorea rhythmic a; or the patient may act as though 
possessed, climb walls, turn somersaults, and perform all sorts of stunts 
—chorea magna. Still more advanced cases of hysteria may be mani- 
fested by attacks of sopor, night terrors, somnambulism, hallucinations, 
delirium and mania. Hammond, in his treatise on "Spiritualism" 
(1876), refers to several journalistic reports of epidemics of hysteria 
as they occurred in this country two centuries and more ago. One of 
the first documents of this kind appeared in a New England paper, in 
1688, and reads as follows : 

Four children of John Goodwin, of Boston, remarkable for their piety, honesty, 
and industry, were in the year 1688 made the subject of witchcraft. The eldest, a 
girl about thirteen years old, had a dispute, about some linen that was missing, with 
a laundress whose mother, a scandalous Irishwoman of the neighborhood, applied 
some abusive language to the child. The latter was at once taken with "odd" fits 
which carried in them something diabolical. Soon afterward the other children, a 
girl and two boys, became similarly affected. Sometimes they were deaf, sometimes 
they were blind, sometimes dumb, and sometimes all of these. Their tongues would 
be drawn down their throats, and then pulled out upon their chins to a prodigious 
length. Their mouths were often open to such an extent that their jaws were dis- 
torted and were then suddenly closed with a snap like that of a spring lock. The 
like took place with their shoulders, elbows, wrists and other joints. They would 
lie in a benumbed condition and be drawn together like those tied neck and heels, 
and presently be stretched out, and then be drawn back enormously. They made 
piteous outcries that they were cut with knives, and struck with blows, and the plain 
prints of wounds were seen upon them. At times their necks were rendered so 
limber that the bones could not be felt, and again they were so stiff that they could 
not be bent by any degree of force. 

The next authentic account is offered by Eev. Dr. Davidson.* While relating the 
proceedings of a Kentucky camp meeting, in the year 1800, the writer remarks that 
"small children had taken part in the religious ceremonies, which consisted in part 
in the following feats: Simple jerking of the arms from the elbow downward. The 
head was thrown backward with a celerity that alarmed spectators, causing the hair, 
if it was long, to crack and snap like the lash of a whip. The children would bounce 
from place to place like a foot ball, or hop around with head, limbs and trunk, 

*History of the Presbyterian Church in Kentucky. 



686 DISEASES OF CHILDREN 

twitching and jolting in every direction. Sometimes the head would be twitched 
right and left to a half round with such velocity that not a feature could be dis- 
cerned." 

This hysterical method of worshiping seems to have been "contagious" in char- 
acter, for about the same time several such epidemics are recorded, foremost of 
winch is that reported by Rev. John Wilkinson,* who realized the morbid basis of 
the religious ceremonies. It may be noted here that this contribution on hysteria 
seems to be the first one ever published in an American medical paper. ' ' This 
disease, ' 7 the divine begins, ' l made its appearance early in the summer of 1803, 
and increased in its effects with astonishing rapidity until the latter end of that 
season. I have known some persons as young as six or seven years of age, and 
others, I think, upward of sixty affected * * * There is scarcely one girl in 
ten between the age of ten to twenty that has not had or now has the exercise 
* * * The paroxysms continued from a half an hour to an hour and upward. The 
agitation consisted in twitching, retching, groaning, jerking and laughing. Pre- 
monitory symptoms were compression or weight in the chest or about the heart. 
The motion gave relief. No other complaints of corporeal pains were made. 

They all agree in asserting that during these exercises the senses remain in full 
vigor, and that even in their silent exercises they know everything that is passing 
about them. They also say that their mental faculties during the paroxysms are 
preternaturally active and strong * * * When a person is in the silent exercise, 
if a pin or a needle be introduced through the skin, it will cause no emotion or 
complaint, but will produce the sensation of pain." 

Epidemics of this kind occurred also in 1835, 1846, and 1870, but 
for the sake of brevity we will omit their full discussion. 

Hysteroepilepsy is comparatively rare in children. An attack is 
usually preceded by emotional excitement, globus hystericus, etc., and 
may be induced by pressure upon sensitive areas — hysterogenic zones 
- — of the body, such as the hypochondriac or spinal regions. Hystero- 
epilepsy differs from genuine epilepsy in the following respects : 

Epilepsy Hysteroepilepsy 

Onset sudden Preceded by emotional excitement 

Consciousness entirely lost Partially preserved 

Convulsions preeminently clonic Tumultuous, accompanied by moaning, 

Duration short, followed by stupor screaming, crying, etc. 

Longer; followed by restlessness 

Hysteria generally proceeds a very chronic course, with temporary 
improvement and relapses. Of course, it very much depends upon the 
etiologic factors, the time when treatment is begun and the energy 
with which it is carried out. 

Without denying the transmissibility from parent to offspring of a 
certain degree of nerve instability which may predispose to hysteria, 



■Philadelphia Med. and Phys. Journal, pp. 87-96, 1805. 



DISEASES OF THE NERVE SYSTEM 687 

in the great majority of instances this disease is acquired as a result 
of harmful influences of faulty environment and education. A child 
repeatedly seeing its mother, for example, in a state of emotional ex- 
citement or frenzy, sooner or later, consciously and deliberately, or 
otherwise, learns to imitate its mother's hysterical performances, the 
habit of imitation gradually leading to aberration of the normal cere- 
bral functions. Unable as the mother is to control her own abnormal 
actions and feelings, she can hardly be equal to the occasion to guide 
her children in the right direction. On the contrary, the child is al- 
lowed to have its own way, is made the central figure of the house- 
hold and spoiled by overtenderness. If, in addition, such methods 
of education are adopted as will overtax the child's mental capacity 
(e. g., the study of music, painting, emotional recitations, etc., in addi- 
tion to arduous school work), a deranged state of mind sooner or later 
supervenes which is most susceptible to the aforementioned pernicious 
influences. Less potent in the predisposition to hysteria are the use 
of alcoholic beverages, acute infectious diseases, prolonged disturb- 
ance of sexual (masturbation!), digestive and circulatory (anemia) 
systems, in fact, anything that will undermine the physical or mental 
condition of the child. 

Treatment. — With these principal etiologic facts in view, the indi- 
cations for the treatment of hysteria in children are self-evident. The 
patient should be removed from the hysterical environments, and 
placed under the care of one who with kindness but firmness can con- 
trol his destiny. Change of residence from the noisy city to the rest- 
ful country often works wonders. The child should lead an outdoor 
life, and every effort should be made to raise his general bodily de- 
velopment. The food should be ample and nutritious, free from al- 
coholic beverages. Milk foods should be given preference to meats. 
The education should be restricted to the simplest school work, or, 
for a time at least, entirely suspended. 

The active treatment of hysteria is essentially symptomatic. "Warm 
baths and cold showers and general massage are useful in all cases. 
Paralysis and contractures frequently yield to electricity, its action 
being probably suggestive in nature. Suggestion by electricity or 
other spectacular procedures are also effective in relieving local con- 
ditions, such as aphonia, stuttering, blindness, and the like. Hystero- 
epilepsy and maniacal outbreaks call for isolation, rest in bed, and 
the administration of small doses of the bromides and valerian. Disre- 
gard of the patient's complaints and severity will often cure some 
hysterical phenomena where kinder therapeutic measures ordinarily 
fail. 



688 



DISEASES OF CHILDREN 



Natrii Bromidi 




3i 


4.00 


Ext. Ilumuli PI. 




3 iij 


12.00 


Infusi Valeriana: Rad. 








Aq. Aurantii Flor. 




aagj 


30.00 


M. 








S. — One teaspoonful 


every 


four hours 


, for a 


child ten years old. 









Dystonia Musculorum Deformans 

(Progressive Torsion Spasm of Childhood) 

At a meeting of the Berlin Psychiatric Society, December 17, 1910, 
Ziehen 1 demonstrated a child ten years of age with a spasmodic affec- 




;;|||;||lf§ 



Pig. 205. — Progressive to 



spasm. (J. Ramsey Hunt.) 



tion of unusual type. Four similar cases had come under his obser- 
vation, three in members of the same family. In all, the affection had 
been gradually progressive and was characterized by spasm and hy- 
pertonicity of the musculature, with curious twisting and torsion move- 
ments of the extremities and trunk. The muscular spasm was 
considerably increased by active movement and diminished during 



iZiehen: Tonic Torsions (Neurol. Centralbl., xxx, 1909; Allg. Ztschr. f. Psychiat. 1911, 
lxviii, 281.) 



DISEASES OF THE NERVE SYSTEM 689 

rest. The gait and station were chiefly affected and there was marked 
lordosis of the spine. The tendon reflexes were present but difficult 
to elicit, because of the tension and torsion of the muscles. Sensation 
and intelligence were not affected, and, in one of the cases, necropsy 
had revealed no essential lesion. All the patients were Russian Jews. 
Since then numerous cases of this affection have been reported by 
J. Kamsey Hunt,* who made a special study of the subject in this 
country. 



*Jour. A. M. A., Xov. 11, 1916. 



CHAPTER XIII 

AMENTIA 

IDIOCY AND THE ALLIED MENTAL DEFICIENCIES 

I. In Infancy and Early Childhood 

Nature and Pathogenesis 

Amentia is not an affection sui generis, a precise morbid entity, but 
merely a syndrome of a large group of congenital and acquired patho- 
logic conditions, principally of the brain and the ductless glands. The 
degree of mental debility is very variable and not rarely incommen- 
surate with the extent and gravity of the causal organic lesion. Thus, 
profound idiocy is frequently encountered with seemingly insignifi- 
cant structural changes in the brain or elsewhere, and vice versa, 
gross brain lesions may occasionally be accompanied by only slight 
feeblemindedness. As a rule, however, definite postmortem findings, 
with predominance of characteristic lesions in certain types of cases 
are observed in the great majority of cases of amentia, so much so, as 
to permit — in accord with the underlying pathologic anatomy — to 
classify idiocy and the allied mental deficiencies into distinct groups 
(e. g., idiocy with microcephalus, hydrocephalus, athyrosis, etc.), which 
will presently receive due consideration. 

In almost all forms of amentia the cerebral convolutions are more 
or less modified and irregular in outline and diminished in number. 
They are either agglutinated or separated by widely gaping grooves. 
Frequently there is an appreciable difference in the size, shape and 
weight of the hemispheres, or an asymmetry of the corpora striata, the 
peduncles, or the pyramids, or even the absence of one or more of these 
bodies. Similar changes are often observed in the cerebellum, and 
occasionally in the pons, medulla and spinal cord. 

Microscopically, we can readily detect an arrest of development or 
disease of the nerve cells of the brain cortex, of the nerve fibers, and 
of the neuroglia. The nerve cells are immature, irregularly arranged 
or numerically deficient. The nerve fibers are greatly diminished in 
number, more especially in the frontal and parietal lobes, which seem 
most concerned with the highest intellectual functions. The neuroglia 

690 



AMENTIA 691 

is quite frequently sclerosed either in certain portions of the brain or in 
its entirety. 

Sclerosis and porencephalia usually predominate among the lesions 
encountered in the different varieties of amentia of infancy; occasion- 
ally, however, neoplasms, especially cysts, and local softening are 
detected postmortem in cases in which they were least suspected dur- 
ing life. 

The cerebrospinal fluid is either increased or diminished in quan- 
tity, depending chiefly upon the size of the skull and the amount of 
brain structure within it. 

In addition to the diverse pathologic alterations in the central nerv- 
ous system, postmortem examination of mental defectives invariably 
discloses also several lesions in other parts of the body. The ductless 
glands, more particularly, the tlryroid, thymus, pituitary and adrenals 
are often in a state of rudimentary development, hypertrophy, or de- 
generation. The cranial bones are either unusually thick or thin, and 
the diploe is diminished. The tubular bones are thick and short and 
often deformed. It is not uncommon to find congenital anomalies of 
the heart and blood vessels, and of the abdominal organs, as also 
malformations of the eyes, ears, palate, fingers and toes. Indeed, these 
anomalies are so prevalent, that they are generally accepted as special 
"stigmata of degeneration" (q.v.), and of great diagnostic importance. 

Contemporary authorities are very much inclined to advance hered- 
ity to the forefront of the etiologic factors of mental degeneracy, Tred- 
gold, for example, going so far as to claim a neuropathic ancestry in 
from 60 to 70 per cent of the cases of amentia. While his estimate 
may precisely agree with the histories of amentia housed in asylums 
and special hospitals for idiots, it seems to me that these percentages 
by far exceed those obtained in private practice. Statistics in this 
direction in order to be correct would have to embrace not only the 
personal and family history of the institutional cases (almost inva- 
riably of the worst stock and lowest class of society, and whose very 
life and environment are conducive to mental degeneracy), but also 
of the even larger number of aments who are quietly kept at home, 
and whose mental degeneracy is the result either of antenatal, natal 
or postnatal traumatism or disease, and who often succumb at an 
early age, not rarely long before the exact state of their mentality has 
at all been determined. 

Those who claim the preponderance of a tainted heredity as the 
primary cause of menal deficiency a priori concur with the views of 
Darwin and his disciples who hold that the offspring inherit the essen- 
tial characteristics of their ancestors. Now, while this doctrine unques- 



G92 DISEASES OF CHILDREN 

tionably applies to the animal species as a whole and to the transmission 
of normal racial characteristics, I very much doubt if it conforms to the 
phenomena of disease, which, in contrast to normal attributes of the 
human species, form abnormal, unnatural, nay, often merely accidental 
accessions. 

In order to obtain a clear conception of the workings of heredity, 
I think it best to assume two distinct phases thereof — namely, one 
permanent, which has become fixed during the long course of evolu- 
tion; the other, temporary, accidental or transient. To the first, 
permanent, category belongs the phenomenon or hereditary transmission 
of normal racial characteristics. Taking the African negro, for exam- 
ple, we find that irrespective of the laws of variation and mutation, his 
offspring always maintain their racial characteristics, so long as the 
negro mates with members of his own clan. And even were he per- 
sistently to intermarry with descendants of the white race, there still 
would be little likelihood of his offspring ever entirely overcoming the 
attributes of their African ancestry. It certainly would require a 
great many generations to swamp the negro individuality, were it at 
all conceivable that the law of reversion would cease its vigilance and 
tolerate such an unnatural process of evolution. This, then, repre- 
sents the permanent phase of heredity. The second, temporary, prin- 
ciple of heredity here suggested is strikingly illustrated by the 
transiency of certain bodily physical anomalies, as for example, super- 
numerary fingers and toes. These malformations are occasionally ob- 
served in several members of one family. But we usually note, that 
just as soon as these affected individuals intermarry with normally 
developed individuals, the aforementioned structural anomalies, with 
but very few exceptions, promptly disappear in their succeeding genera- 
tions, for the very good reason that supernumerary fingers and toes 
are useless, abnormal and unnatural acquisitions, and hence are 
dropped by nature at the earliest opportunity. This phase of tem- 
porary heredity applies with equal force to anomalies of development 
of the central nervous system. Indeed, so anxious is nature to elimi- 
nate anomalies of development, be they physical or mental, that the 
great majority of degenerates are destroyed in the germinal, embryonic, 
fetal, or early postnatal stages of life, or if they happen to survive, 
are usually rendered sterile, in order to prevent the procreation of 
their kind. 

With these considerations in view, I cannot help but hesitate to be- 
lieve that heredity really plays so important a role in the propagation 
of mental deficiencies as is generally supposed, and am inclined to 
place much more responsibility upon acquired etiologic factors. This 



AMENTIA 693 

reasoning is partly corroborated by the investigations of Scholomo- 
witch, Keller and Diem who found that the difference in the degener- 
acy ratio among the offspring of sane and insane ancestry is only 
about 10 per cent in favor of the former. 

The fact frequently cited that on rare occasions (e. g., the famous, 
or rather notorious Jukes family) we do meet hereditary mental de- 
generacy in several generations, does not in the least controvert the 
here proposed modification of Darwin's theory. In fact, in a way it 
even confirms it, since it can readily be shown that, as a rule, mental 
degenerates persistently mate with individuals of similar mental caliber 
(for anyone with sound mind could hardly be induced to mate with an 
idiot ! ) , and therefore the continuity of intermarriage among defectives 
generates the phase of permanent heredity previously spoken of ; in other 
words, a new race, as it were, with mentally deficient characteristics, is 
created which does for some time and would forever transmit its de- 
generacy to its offspring, were it not exterminated by nature in accord- 
ance with the law of natural selection and destruction of the unfit. 

The modus operandi of hereditary transmission is still veiled in deep 
mystery. It is generally assumed that in mental degenerates the germ 
plasm of the male or female, or of both, is defective either in the num- 
ber of its component cells, in their strength, or shape, and in consequence 
fails to form the impetus essential to normal development of the brain. 
It is further postulated that under certain as yet mysterious conditions 
the germ cells of the opposite sexes, at the time of their fusion, are 
capable to influence each other, either for good or bad, in accordance 
with the laws of natural selection. In all probability a tainted germ 
plasm is deficient in more than one of its elements, since the degenerate 
brings into the world not only a deteriorated brain but quite frequently 
also several anomalies of other parts of the body, e. g., abnormal heart, 
extremities, etc. Furthermore, there is ample reason for the belief that 
the anteconceptional deficiencies in the germ plasm which are produc- 
tive of amentia in the child may be the result not only of neuropathy in 
the parents, but also of other pathologic states, more especially tuber- 
culosis, cancer, syphilis, and the like, the toxins of which act as poison- 
ing and deteriorating agents upon the germ cells, the embyro and fetus, 
and arrest their normal development. Statistics are greatly at variance 
as to the exact number of the feebleminded children procreated by par- 
ents thus afflicted. The family histories obtained are almost always 
inaccurate, since but very few parents are willing to admit or are 
aware of the prevalence of latent tuberculosis, syphilis, etc. amongst 
them. Moreover, it is only with the evolution of the \Vassermann and 



694 DISEASES OF CHILDREN 

tuberculin reactions that the statistics pertaining to the causes of 
feeblemindedness have at all become reliable. 

All observers agree that parental alcoholism forms a most potent 
predisposing cause of mental degeneracy in the offspring. In 1901 the 
New York Academy of Medicine undertook a careful investigation 
of the effect of parental intemperance upon their children. The 
family history of 3,711 school children through three generations 
was traced with considerable detail, and it was found that the chil- 
dren of temperate parents exceeded' in proficiency those of heavy 
drinkers by about 70 per cent, and that a large number of the en- 
cumbered children were mentally deficient to a very high degree. 

The etiologic relation of consanguinity to amentia is still subject 
to controversy. It undoubtedly greatly depends upon the physical 
and mental condition of the individuals concerned. However, it has 
often been observed that all hereditary predispositions to disease in 
the parents are markedly intensified in the offspring. Deaf-mutism 
is particularly prone to occur as a result of union of near relatives. 

The postconceptional causes of mental deficiency acting upon the 
embryo and fetus are as prolific as, and possibly more so than, those 
exerting their influence through heredity. Notwithstanding the purity 
and the normal activity of the parental germ plasm, it may yet fail in 
its destiny, if the soil in which the seed is to grow is lacking in the es- 
sential prerequisites for healthy growth and development. Let me 
briefly enumerate the various intrauterine morbid conditions which 
tend to disturb the normal progress of the embryo or fetus — in one 
case, e. g., acting harmfully upon the extremities or heart; in another, 
upon the central nerve system : 

1. Disease of the uterine tissues surrounding the impregnated ovum 
preventing uniform contact between the maternal and embryonic struc- 
tures and facile absorption of nutriment. 

2. Internal or external violence acting either directly or indirectly 
upon the fetus. 

3. Intra- or extrauterine excessive pressure hampering the commodious 
and equable expansion of the rapidly growing fetus. 

4. High degrees of toxemia from febrile affections or poisoning from 
slow morbid metabolic processes, e. g., typhoid, tuberculosis, and dia- 
betes, especially during the early period of pregnancy, may greatly 
affect the fetus, and finally, 

5. Serious domestic trouble, grave mental anxiety and extreme 
fright with prolonged agitation during the early stages of pregnancy 
may so undermine the general health of the mother as to disturb in- 
directly the normal processes of growth and mental development. 



AMENTIA 695 

111 this connection it is not amiss to emphasize also that many of the 
dystrophies, especially of the brain, not rarely observed in prematurely 
born infants, are the direct or indirect result of some microscopic or 
gross pathologic changes either in the thyroid, parathyroids, thymus, 
adrenals or the hypophysis originating at an early period of intrauter- 
ine life. 

There still remains another large group of mentally deficient infants 
who though apparently normal until birth, show definite manifestations 
of amentia some time thereafter. Traumatism during delivery has 
always been recognized as a highly potent factor in the production of 
idiocy and the allied mental deficiencies, the statistics relative to these 
cases ranging anywhere between 15 and 30 per cent. Where the cranial 
bones are fully developed and the maternal pelvis is free from extreme 
contraction or deformity, it is doubtful whether tedious labor per se 
is responsible for mental deficiency developing during early childhood. 
On the other hand, forcible instrumental delivery of a soft skull im- 
pacted in a narrow rickety pelvis is bound to effect some injury to the 
brain and leave behind a permanent mental deficiency in the child, 
more especially if the parietal and frontal lobes sustain the brunt 
of the injury. Occasionally severe asphyxia neonatorum is traceable as 
an immediate cause of amentia, undoubtedly owing to suggillation of 
and quite severe hemorrhage in the meninges and even in the brain that 
often accompany prolonged asphyxia. Amentia, following natal trau- 
matism, not rarely makes its appearance several months or years after 
the injury has been received, and is often preceded by epileptic con- 
vulsions which are attributed to all sorts of immaterial causes. Trau- 
matism in early infancy is an especially frequent cause of mental de- 
generacy in children of the slums, whose parents, either for want of 
means or of good sense are very apt to leave their small children to shift 
for themselves, so that knocks, falls and bruises form part and parcel 
of the miserable lot of their unfortunate babies. Apparently "the Lord 
takes care of the helpless children," for were it otherwise the hordes of 
idiots would have swelled beyond calculation or imagination. 

Febrile affections, more particularly meningitis, encephalitis and 
exanthemata form very material etiologic factors of permanent de- 
generation of the infantile central nervous system. Acquired hydro- 
cephalus supervening upon grave gastroenteric intoxication, severe at- 
tacks of pertussis (by inducing cerebral hyperemia or local hemorrhage), 
and acquired diseases of the thyroid (e. g., endemic cretinism) most prob- 
ably stand next in frequency as etiologic factors of amentia. Not rarely 
also mental backwardness is traceable to deprivation of senses, such as 
vision and hearing, particularly if these unfortunate children are not 



696 DISEASES OF CHILDREN 

given the benefit of expert treatment and training. Several authors 
mention malnutrition, rachitis and adenoids as rampant causes of men- 
tal deficiency in young' children. The mental dulness, however, in these 
cases is only temporary, promptly giving way to full vigor upon re- 
moval of underlying, mentally retarding, factors. 

Diagnosis. — After reviewing the aforementioned intricate causes of 
amentia, we can readily appreciate the importance of obtaining a clear 
personal and family history of the case in question. It is especially 
essential to learn whether the amentia is congenital or acquired, since 
it furnishes the most reliable clue to the prognosis and treatment of the 
case. In taking the history, however, it is almost equally important to 
remember that histories obtained from parents are not always re- 
liable, first, because the latter are rarely very certain of their own 
mental shortcomings, and more especially of those of their ancestors ; 
secondly, they are usually loath to admit degeneracy in their immediate 
family; and thirdly, either for want of good judgment, or in the hope 
of favorably influencing the doctor's opinion, they are very apt to con- 
ceal certain mental inferiorities of their infants or to exaggerate their 
mental powers and thus to mislead the examiner. However, unreliable 
as the history may be, it always furnishes at least a few threads of in- 
formation which help to direct our attention to some mute points in the 
diagnosis, which otherwise would escape our observation. 

The taking of the family history should include questions as to in- 
sanity, idiocy, dipsomania, syphilis, tuberculosis, cancer, epilepsy and 
monstrosity in the immediate family, both on the father's and mother's 
side. The condition of the previously born children, if any, at the time 
of birth and thereafter. Diseases of the mother immediately before and 
during pregnancy. The mental state of the mother during pregnancy, 
especially as regards grief, fright or extreme emotion from other causes. 
Traumatism during pregnancy, possible means used to abort, drug 
habits, etc. 

The past and immediate history of the patient should furnish us all 
details as regards asphyxia, bleeding from nose and mouth and injuries 
during labor. Appearance of the head and other portions of the body 
immediately after birth. Convulsions at this time or at any time there- 
after. Mode of feeding and physical progress of the child. Diseases 
it suffered from, particularly as to exanthemata, pertussis and otitis. 
Traumatism and its immediate consequences. The period at which the 
infant was able to hold its head erect, to sit up, to stand and to walk, 
when the teeth made their appearance ; and also the age of the baby when 
it made the first attempt to speak. It is also advisable to let the mother 
relate in her own way what she observed of the mental acumen of her 



AMENTIA 697 

child, more especially in reference to its progressive or regressive char- 
acter. This is important, as we intend to show later that some idiots, 
e. g., cretins and amaurotics, get more stnpid as they grow older. 

Lest we forget, let me state right now that while the parents are busy 
relating their "experiences" and responding to questions, and the pa- 
tient is still in a passive mood unmolested and nnaronsed by the ordeal 
of the physical and mental examination, the physician should avail him- 
self of the opportunity to note the attitude and behavior of both the 
parent and the child and "to size up" the general aspect of the case. 
Indeed, as with increased experience we gradually learn to see aright, 
it is often surprising how easily we can arrive at a correct diagnosis by 
mere superficial observation of the patient. This statement is not in- 
tended to convey the idea that such momentary examination should 
suffice to express a positive diagnosis. Quite the contrary ; irrespective 
of what impression we gain at a glance, we must never omit a very care- 
ful and minute physical examination of the child and, this completed, 
to apply all the mental tests presently to be outlined. But I do desire to 
lay special stress upon the importance of training ourselves to see a 
great many things at a glance. After undressing the child we proceed 
with the usual physical examination of children, but devote a little 
more attention to inspection and mensuration (see p. 173) which enables 
us to reveal the pathognomonic signs of amentia and more particularly 
the stigmata of degeneration which are invaluable in the differential 
diagnosis between congenital and acquired amentia, and should inva- 
riably receive careful consideration. Therefore let us briefly enumerate 
them. 

Stigmata of Degeneration 

1. Abnormalities in the size and shape of the head. Softness or 
bossing of the cranial bones. Marked gaping or premature closure of 
the fontanelles and sutures. Undue distention or sinking of the fon- 
tanelles. 

2. Malformations of the ears. Irregularity in size. Undue promi- 
nence or flattening. Misshaped helix, antihelix, tragus, antitragus and 
lobule. Supernumerary auricles, auricular appendages or atresia auris. 

3. Anomalies of the eyes or lids. Drooping of one or both eyelids. 
Epicanthus and palpebral fissures. Congenital cataract, coloboma iridis 
or irideremia. Micro- or anophthalmias. Strabismus, and nystagmus. 

4. Malformations of the nose. Saddle-shaped, exceptionally small 
and broad, or unduly large and prominent. Partial or complete atresia 
of the posterior nares. 



698 DISEASES OF CHILDREN 

5. Malformations of the face. Undue prominence of the cheek bones 
with markedly retracted small chin. Clefts of face and lips. V-shaped 
or high vaulted palate. Enlarged protruding and often cracked tongue. 
Irregularly shaped and implanted teeth, deficiency or excess in their 
number. Inability to bring jaws closely together owing to irregularity 
of dental arches, hence constant dribbling of saliva from half open 
mouth. 

6. Malformations of long bones. Curvatures of the bones of the 
upper and lower extremities. Supernumerary fingers and toes or de- 
ficiency in their number. Syndactylism or fan-shaped distribution. 
Disproportion in size of legs and arms. Talipes, spina bifida, and caudal 
formations. 

7. Umbilical hernia : diastasis recti abdominis. Anomalies of the 
genitalia ; epi- and hypospadias. Malformations of the rectum and 
anus. 

Valuable as a tainted history and the existence of stigmata of degen- 
eration are as diagnostic aids in amentia ; they are at best only of rela- 
tive value in estimating the mental state of the child in question. It 
is not at all unusual to meet with perfectly normal children who present 
a neuropathic history and several bodily malformations, and vice versa. 
Furthermore, infants of certain Mongolian races naturally possess the 
typical Mongolian facies and yet may be fully as intelligent as, and 
possibly more so than, a child of the purest white race with an un- 
blemished history and anatomy. Hence, before declaring an infant 
mentally deficient, it is absolutely indispensable to put it through defi- 
nite physical and mental tests, which reveal the mentality of children of 
certain ages and permit not only the distinction between the normal 
and abnormal mentality, but the degree of mental deficiency as well. 
The importance of such an examination becomes especially evident when 
we bear in mind the fact that some infants are merely slow in their 
mental development as a result of diseases or faulty environment, but 
promptly unfold their mental powers under proper care and treatment. 

In order to be able to estimate the mentality of an infant correctly, 
we must, of course, have a perfectly clear conception of the normal in- 
telligence at different periods of its existence. We shall, therefore, 
endeavor to depict the normal mentality of the infant before attempting 
to outline the mental tests for one who is less gifted. 

Normal Intelligence 

According to the latest investigation, a normal baby can hear and see 
immediately after birth. He feels pain when he is hurt and cries when 
he is uncomfortable or hungry, and exercises his extremities and the 



AMENTIA 699 

musculature of other portions of the body,- — if not immobilized by an 
overabundance of coverings, or fancy frocks and frills and bows and 
strings. 

At one month he begins to locate the direction of sound and momen- 
tarily to follow a bright light. 

At two months he responds to snapping of the fingers, follows bright 
objects more or less intently, and rejects ill-tasting food or drugs. 

At three months he holds his head erect, and can turn it steadily 
from side to side ; he smiles when accosted, shows an inclination to grasp 
bright objects displayed in front of him, and coos when in good humor. 

At four months he begins to recognize his mother or nurse, or those 
who fondle him ; manipulates things put in the hand, e. g., a rattle ; 
plays with his fingers, and brings everything to his mouth. 

At five months he knows his mother, nurse or father, and puts out 
his hands to be taken when they approach. When crying from hunger 
he stops promptly as the food is brought near, and opens his mouth — 
ready for the prey. 

At six months he is interested in his surroundings ; sits up in a chair 
with slight support ; shows gratification when taken outdoors. 

At seven months he recognizes familiar faces from a distance; grasps 
after objects placed at a short distance ; begins to imitate sounds and 
syllables;* laughs aloud, and smiles to everybody, and cries when 
scolded. 

At eight months he attempts to stand if held erect or to creep if 
placed on the floor. He is often able to repeat "mama" or "papa," to 
clap hands, to shake bye-bye and to perform similar little ' ' baby tricks. ' ' 
He understands several words spoken to and enjoys a game of "peep 
bo" and the like. 



*N. J. P. Van Baggen (of the Hague, Holland) distinguishes different periods in the de- 
velopment of the infant's speech. In the first period during the first year, the infant utters 
involuntary sounds, which must be considered as a simple muscular action of the apparatus 
of speech produced by an unconscious reaction of the numerous stimuli which the child re- 
ceives from without. Later on the stimuli, becoming more intense, reach, through the spinal 
marrow, the centers of the cortex, and the child begins to feel the muscular movements and 
to be conscious of them. About the same time, however, the child begins to hear the sounds 
he produces. Henceforward he feels those sounds as well as he hears them. Both sensations 
now leave their traces on the cortex of the brain in those parts which are destined for 
the motor center of the muscles of articulation and for the center of hearing. The sensation 
of feeling, and that of hearing the word, occur simultaneously and therefore they become 
united by simultaneous association. The child now begins to imitate the sound he produces 
himself and soon thereafter he notices the sounds produced by others and he tries to imitate 
them. 

The child now commences to appreciate the conformity between the sounds he hears and 
the sounds he utters; the imitation becomes more and more complete; and finally, syllables anu 
simple words are pronounced. However, this pronouncing of words has not yet any meaning 
for him. It is only gradually that the association between the heard and pronounced word ana 
the realization of its significance takes place. This association is brought about by the simul- 
taneous hearing of the word and the seeing of the object which the word indicates. Whenever 
the child sees his doll, the word doll is repeated till at last the child unites the word doll 
inseparably with the object itself, and henceforward the heard word and its characteristic 
meaning are fixed in the child's memory. The child enters the third period when he begins 
to use the words which he knows by memory. When he wants his doll, he will pronounce the 
word even without seeing the object or hearing die word pronounced by standers-by. 



700 DISEASES OF CHILDREN 

At nine months he knows his name and also turns in the directions 
of other persons who are accosted. He easily holds and carries his 
bottle to the month; is able to bite off and masticate solid food. If 
properly trained, he indicates his desire to urinate and defecate. 

At twelve months he stands alone, or by holding on lightly to a hand 
or chair, and in the same manner attempts also to walk. He knows 
the difference between the articles of food he is accustomed to eat. He 
throws a kiss or actually kisses. 

At fifteen months he makes himself thoroughly understood either by 
signs and motions, or by baby language. He can point to the nose, 
eyes and ears, etc. He is interested in picture-books, colors and differ- 
ent toys; can turn pages and scribble with chalk or pencil. He knows 
the difference between a cat and a dog, and is often able to name them 
from life or drawings. He can play a toy piano or mouth-harp. 

At eighteen months he usually runs about freely and engages in 
several games, such as throwing balls, marbles and the like. He can 
imitate all sorts of performances, such as dance, jump, hide, rock a 
doll, etc. He knows the difference between right and wrong, and obeys 
or rebels. 

At two years he knows exactly what he wants in the way of food or 
toys, and as a rule, is able to call for them. He speaks with character- 
istic gestures; is able to feed himself, and to distinguish manifestations 
of the weather (snow or rain). 

At two and a half years he can make himself, as it were, useful 
around the house, i. e., do little errands. He begins to ask questions and 
to "show off." He recognizes different colors, shows constructive abil- 
ity by making correct use of building blocks, etc. ; carries simple tunes 
and memorizes more or less lengthy nursery rhymes. 

At three years he uses the personal pronoun in conversation. He 
shows an inclination and some ability to dress himself. He can indicate 
the seat of pain or annoyance. If instructed he can count up to ten, at 
least, and spell simple words, or pick several letters of the alphabet. 

The physical and mental activity of the child here depicted pertains 
of course to that of average normal intelligence. Some infants excel 
others in certain capacities, and vice versa. It is not at all uncommon, 
for example, for some babies to walk and to talk at one year of age, or 
conversely, barely to begin either at two years or even later, and yet be 
perfectly normal in every other respect. But we must set before us a 
standard of the average and not of the exceptional baby, and with due 
allowance for delay of development as a result of disease or lack of 
training, compare the physical and mental activity of the baby under 
examination with that of the assumed normal standard. 



AMENTIA 701 

Judging from the foregoing discussion, a normal infant is supposed 
to acquire the power of seeing, hearing, taste and touch when he reaches 
the first four months of his life; attention, voluntary motion and per- 
ception during the second four months; imitation, speech and under- 
standing in the third four months, and gradually, from month to month, 
to unfold and to strengthen these qualities, so that at the age of about 
three years he has developed into a real human being intellectually. 
Let us now attempt to analyze those qualities as they are manifested in 
mentally deficient children and to suggest workable mental tests to 
facilitate their early recognition. 

THE ABNORMAL BABY 

Vision. — As a rule idiots gaze vaguely into empty space or irregularly 
rotate their eyes in all directions. They rarely follow a bright object 
placed before them and it is almost impossible to fix their attention 
upon one point for more than a few moments. In testing their power 
of vision, however, we must assure ourselves of the absence of congenital 
or acquired obstruction to vision, e. g., congenital cataract, large staphy- 
lomas and the like. Sollier maintains that blindness is encountered in 
from 7 to 8 per cent of idiots. The importance of an early ophthal- 
moscopic examination of the eyes cannot too strongly be emphasized, 
since by this means only are we able to detect optic atrophy, symmetrical 
changes in the macula, and choroid tubercules, which are often decisive 
in the diagnosis of amentia of cerebral origin. 

Hearing. — The sense of hearing is easih T tested by starting some sort 
of a noise (ringing of a bell, clapping of the hands) while the patient 
is unawares. The ament who hears will ordinarily be startled by the 
noise, at least momentarily, even though he usually fails to turn in the 
direction of the noise. Some aments, e. g., amaurotics, are often vio- 
lently startled by the slightest clapping of the hands. Deafness in 
connection with amentia is a rare congenital anomaly and almost never 
forms the sole cause of true mental deficiency. (See p. 730.) 

Sense of Taste and Smell. — One of the very earliest signs of amentia 
is obtuseness or perversion of the sense of taste. Aments either chew 
everything put in their mouths, regardless of its disgusting taste, or 
conversely, spit out the most pleasant delicacies, because of their in- 
ability to detect their agreeable taste. They relish quinine as greedily 
as sugar, or refuse both. This perversion of taste explains why some 
aments are gluttons and others again barely eat enough to sustain life. 
The sense of smell is equally affected, but cannot be tested with any 
degree of exactitude until the child has attained considerable intelli- 



702 



DISEASES OF CHILDREN 



gence. Some clinicians record lack of local or reflex response to irri- 
tating odors, such as ammonia. In these cases, however, we are most 
probably dealing with malformations of the nose (e. g., atresia), so 
that the strong odor does not at all reach the olfactory nerve. 

Sense of Touch, Pain and Temperature. — Almost all confirmed idiots 
are insensitive to pain and temperature, hence are frequently seen 
burnt, bruised and bitten without showing any signs of discomfort. 
Indeed, some of them delight in mutilating themselves. It is of daily 
experience to find a mentally deficient child squatting on the floor, bed 
or chair, rocking to and fro, diligently cracking his fingers or biting 
his hands, often until they bleed, and rebelling and howling if inter- 
rupted in his apparent state of enjoyment. So characteristic and im- 




Fig. 206. — Microcephalic idiot. Status Idioticus. Fig. 207. — Amaurotic idiot. 
(Peculiar attitude assumed by idiots in sitting posture.) 

pressive is this peculiar attitude of the anient that a few years ago I 
ventured to describe it as the "Status Idioticus" (Figs. 206 and 207). 
In congenital amentia there is frequently general anesthesia, while in ac- 
quired cases the anesthesia is not rarely localized over large areas of the 
body, more especially in connection with paralysis. Tactile sense is not 
nearly as obtuse as that of temperature or pain, in fact, some aments, like 
the blind, show a distinct hyperacuity of tactile sensibility, being able by 
mere touch to recognize the individuals who take care of them. 

Attention, — No other defective mental action so readily betrays the 
mental incapacity of an infant as his lack of power of attention. As 
already stated, a normal infant barely three months old, shows his 



AMENTIA 703 

power of attention by turning in the direction of the sonnd of a bell, 
for instance, and watches the course of a bright object slowly passed be- 
fore his eyes. The anient of a mnch more advanced age, on the other 
hand, is entirely unconcerned about what is happening around him. He 
may suddenly start when frightened by a flash of lightning and he may 
be aroused from his lethargic state by the approach of one who takes care 
of him, but he immediately falls back into his callosity just as soon as 
the artificial agitation has subsided. He is entirely devoid of initiative 
and spontaneity, and may for hours sit huddled up in one spot as long 
as he is not disturbed from sucking his thumbs. 

Perception. — This utter incapacity of attention, of course, goes 
hand in hand with dulness of perception. The less attention the anient 
pays to the doings and actions of others, the fewer are the impressions 
that reach his brain, and the less capable is his cerebrum to perceive out- 
side impulses. Moreover, his memory is so flighty that he is unable to 
treasure up for future use the impressions he receives. Again and 
again, for example, will idiots suffer pain from the effects of burns or 
other injuries, and yet when exposed to the same or similar harmful 
forces, they will not at all attempt to guard themselves against injury, 
for the very reason that frcm one time to another they forget what 
happened to them under such circumstances. They rarely recognize 
familiar faces and cannot differentiate one object from another unless 
specially trained in this direction. 

Imitation. — In view of faulty memory, attention and perception, it 
is hardly to be expected that a degenerate of this sort would be capa- 
ble of imitation. It is true, some of them do perform little tricks 
after repeated training, more especially when encouraged by mother 
or nurse, but their activity is extremely limited, and their perform- 
ance very awkward. Unlike normal infants they do not "show off" 
spontaneously. Very often after learning one movement they keep 
on repeating the same almost indefinitely, or until they have managed 
to learn something else to replace it. The same lack of power of 
imitation hinders them from engaging in any kind of games, and, later 
in life, to learn to read or write, or to acquire mechanical skill to 
practice a trade, although, exceptionally, some aments do show con- 
siderable constructive talent and ingenuity. 

Voluntary Motion. — Profound amentia is invariably associated with 
muscular insufficiency and incoordination. Not only are mentally de- 
ficient infants lacking in initiative to grasp objects displayed before 
them, but even if objects are placed in their hands, they are usually 
incapable of getting a firm hold of, or to manipulate, them. As a rule, 
they are unable to measure distance ; hence, like the blind, they feel 



704 DISEASES OF CHILDREN 

their way in different directions, if they ever manifest a desire to 
locate a certain object. Amentia is frequently accompanied by paraly- 
sis of the extremities, but even in its absence aments very rarely be- 
gin to walk before two or three years of age, chiefly because they are 
slow to learn the special voluntary movements required in the primary 
act of walking. In a similar manner they rarely learn to feed them- 
selves with a spoon; they are sure to spill its contents before bringing 
it to the mouth. Quite a number of aments seem to experience con- 
siderable difficulty also to manipulate the tongue, which possibly ex- 
plains their frequent inability to masticate solid articles of food. 

Speech. — Marked delay to w T alk as well as to talk is almost pathog- 
nomonic of amentia. Occasionally, a mentally deficient infant may 
succeed in repeating a few single short words at an early age, but he is 
never able to pronounce correctly several words in succession so as 
to form an intelligible sentence. Some aments, as they get older, 
keep on chattering incoherently and without measure, but they are 
no wiser than the others who never utter a single syllable. Hence in 
judging the mental capacity of the idiot, it is not the number of words 
he can pronounce that counts, but the way he speaks and what he 
says. Aments often bring out the Avords in staccato fashion — slow, 
broken or "scanning," and having, as a rule, an imperfect image of 
words, cannot pick the right words for the particular things they 
desire, and therefore fail to make themselves understood. 

Intelligence. — All the aforementioned attributes of the brain col- 
lectively serve to mould the human intellect as a whole. But an in- 
fant may be able to see and to hear, smell and taste, pay attention, 
imitate, perceive outside impressions and, finally, to walk and to emit 
sounds, and yet not be endowed with normal human intelligence. 
Practically every domestic animal possesses these faculties. The 
human mind differs from that of the lower animal by its acquired 
faculties (not instinct) to distinguish right from wrong, to reason, 
judge, associate ideas, and to act spontaneously from previous expe- 
rience. Now, while a properly trained infant, let us say of three 
years, fully appreciates that he is wrong to get soiled, reasons how 
best to avoid punishment, e. g., by putting the blame on someone else, 
associates ideas, by looking for paper when you hand him a pencil ; uses 
judgment, by not attempting to cross the street when seeing an auto- 
mobile approaching, and finally, shows spontaneity and power of im- 
agination, by making use, for example, of a box, string and cane, to take 
the place of a horse, whip and wagon, the mentally deficient child is 
utterly lacking all these mental capacities and performs certain ac- 
tions only automatically by imitation after persistent training. Of 



AMENTIA 705 

course, not all aments are alike in their mental acumen. We must 
always bear in mind that there are different degrees of amentia, just as 
there are variously gifted normal infants. But whereas the normal child 
through outside influences easily and readily acquires certain mental 
qualities as he gets older in months and years and experience, the 
abnormal child, owing to some faulty congenital or acquired anomalies 
of the brain is unfolding those mental powers at a very much later 
age, if ever. And it is with the object in view to determine to which 
period of life the mental capacity of the infant under examination — 
as compared with the average normal child — corresponds, that we 
shall presently endeavor to outline helpful mental tests for our guid- 
ance. 

Mental Tests- 
Mental Age, Six Months. — Move bright object in front of the child; 
note if he follows it, Ring bell at a distance of about 2 feet from the 
baby ; note if he turns around. 

Prick the baby's skin lightly with the point of a needle; watch for 
prompt facial expression of annoyance. 

While the baby drinks his milk mixture, remove the bottle from his 
mouth and substitute a bottle containing a trace of quinine, salt or 
nux vomica, or warm water. Note how he takes any of the solutions. 
The normal baby shows the possession of the sense of taste by 
promptly refusing even the plain water. 

Hold the baby's food at a short distance; watch the baby's facial 
expression of satisfaction and desire to grasp the bottle or breast. 
Let the mother leave the room and return from another direction; 
note promptness of attention. 

Put the baby on the mother's lap and note his power to hold his 
head erect and to sit up with but slight support. 

Mental Age, Twelve Months. — While unawares, call infant from a 
distance; note if he turns in the direction of the voice. 

Put a colored object in the baby's hand, then place in front of him 
some article of food the baby is especially fond of; note if he drops 
the toy and reaches out for the food. 

Let the mother encourage her baby to clap hands, shake "bye-bye" 
and perform similar "baby tricks"; note its power of imitation. 

Mental Age, Eighteen Months. — Engage the baby in simple games, 
such as throwing ball and the like ; note his dexterity. 



*In infants of a year or older it is preferable to let the mother apply the mental tests, lest 
the child be unduly disturbed by a stranger. 



706 DISEASES OF CHILDREN 

Hand the baby a pencil and some article of food; note his under- 
standing of their use. 

Let the mother encourage the baby to repeat "papa," "mama" or 
similar words; note his j)ower of articulation of syllables and words. 

Mental Age, Two Years. — Learn whether the baby knows his own 
name and that of his mother, brother or any other member of the 
family. 

Hand the baby some article of food; note his power to bite and mas- 
ticate. 

Put in front of the baby some constructive toy; note its power to 
manipulate the same, e. g., to "build a house" of wooden blocks. 

Ask the baby to point to his nose, mouth, eyes, etc.; note promptness 
of response. 

Mental Age, Three Years. — Encourage baby to repeat several num- 
bers or short nursery rhymes he was taught to recite, or to sing; note 
his power to memorize. 

Place the child in front of a window and let him tell you what he 
sees on the street ; note his ability to distinguish men from animals or 
objects. 

Show him a picture-book with different animals and ask him to 
point to a horse, cat, bird, etc. ; note the ease of response. 

Display several pictures of relatives and let him pick those of par- 
ents. 

Direct him to bring you different small objects from the bureau 
drawers or closets : note his way of going about it and the ease with 
which he locates them. 

If already instructed, ask him to spell his name, to count, etc. ; note 
his memorizing power. 

Mental Age, Four Years. — Test his ability to feed himself with 
spoon or fork. 

Let him reply to the following questions: Where do you live? 
Where do you sleep? What did you have for luncheon today, or, 
possibly, yesterday? How old are you? Almost all normal children 
of four years are able to respond promptly to these questions, or to 
similar ones. 

Let him pick out several letters of the alphabet, especially those 
required to spell his name ; note the ease with which he accomplishes 
it. He is usually able to do it, if previously entertained with toy 
alphabets. 

Classification 

In addition to these simple tests which serve to establish the diag- 
nosis of amentia in general, we have a number of pathognomonic clin- 



AMENTIA 



707 



ical syndromes which in view of their usual occurrence with certain 
lesions in the brain and ductless glands, enable us to classify amentia 
in the following; distinct clinical groups : Amentia symptomatic of 
microcephalus, hydrocephalus and cerebral hemorrhage and inflam- 
mation; amaurotic family idiocy; mongolism; cretinism or myxidiocy, 
infantilism and mental retardation (moramentia) from other causes all 
of which will presently receive full consideration. 




Fig. 208. — Microceplialus — miniature brain. 

Microcephalus 

From a large number of cases under observation I have been 
tempted to distinguish two forms of microcephalus. One, in which 
the brain as a whole is very miniature, but not deficient in its com- 
ponent parts, thus showing arrest of development, but not a state of 
disease. The second variety is characterized by an absence or degen- 
eration of several components of the brain, such as the peduncles, 



708 



DISEASES OF CHILDREN 



pyramids or even an entire hemisphere. In these cases there may 
even be an hydrocephalus in conjunction with the microcephalia. In 
the first variety of microcephalus (Pig. 208) the skull is thick, very 
small and sometimes deeply furrowed. The cranial sutures are ef- 
faced and the fontanelles completely ossified. In the second variety 
(Fig. 209) the reverse may be the case. Indeed, in some microcephalics 
the skull may be moderately large and irregular in shape ("dome" 
or "sugar-loaf" — see Fig. 206). In microcephalics there is often also 
a hypoplasia of the spinal cord, more especially of the pyramidal tracts 
:ind the columns of Goll. 




Fig. 209. — Microcephalus — brain degeneration. 



Where the brain is intact but miniature, there is general inactivity 
of the cerebrospinal system. The child is entirely helpless during 
infancy, but occasionally gradually improves physically as he gets 
older. As the cranial bones are completely ossified, and the immature 
brain no longer has the facility to develop, the mental faculties of the 
child remain permanently in an infantile state. On the other hand, 
in the second variety of microcephalus the mental and physical condi- 
tion of the child depends entirely upon the pathologic alterations of 



AMENTIA 709 

the brain. Where the motor area is involved, we have disturbance 
of locomotion, convulsions, athetosis, rigidity and many other symp- 
toms that usually accompany cerebral lesions. The mental state of 
the child ranges from feeblemindedness to profound idiocy. As these 
children get older, they are usually obstinate, vulgar and very irri- 
table. Some of them understand simple words addressed to them and 
are able to imitate certain actions after prolonged training. They 
may learn to feed themselves, to do little errands, and possibly to 
help in some trade under the guidance of a master. The majority of 
them, however, are entirely devoid of understanding and take no 
interest in their surroundings; and especially while under three or 
four years of age, they may for hours sit or lie in one position and in- 
dulge in irregular movements, without by attitude or facial expres- 
sion indicating any desire for a change or even betraying any dis- 
comfort during or after defecation or urination. Owing to their ex- 
treme restlessness and awkwardness of locomotion, their grotesque 
movements, in hopping from place to place, often resemble those of 
rabbits, goats or monkeys, and in times bygone they were exhibited 
by showmen as curious descendants of a lost degenerated tribe. Some 
of them are witty and alert and show distinct powers of mimicry, but 
they never attain a sufficiently high degree of intelligence to earn 
a livelihood independently. 

The diagnosis of microcephalus is based principally upon the size 
and shape of the head. In the first variety of microcephalus, where 
owing to early arrest of development of the brain the cranial bones 
ossify before or immediately after birth, the circumference of the 
skull always remains from 3 to 6 inches below that of the average 
normal child. To a slighter extent (2 to 3 inches) this is true also of 
the second variety of microcephalus. The hair is often so coarse and 
wiry that as Tredgold puts it, the teeth of the clippers often break 
whilst the hair is being cut. A microcephalic idiot may sometimes be 
mistaken for a Mongolian. In mongolism, however, the head is not 
quite as small or malformed, the hair not as coarse, and the muscular 
flaccidity or rigidity not quite as pronounced, while in microcephalus pro- 
trusion and cracking of the tongue is exceptional. In early infancy the 
mentality of the Mongolian is on a higher plane than that of the micro- 
cephalic idiot. The flaccid type of microcephalus may occasionally re- 
semble amaurotic family idiocy. In the latter condition, however, there 
is usually a history of gradual degeneration after birth; the fontanelles 
are usually open, the size and shape of the head fairly normal, and an 
ophthalmoscopic examination reveals pathognomonic changes in the 
retina (q. v.). The aforementioned symptoms of microcephalus are also 



10 



DISEASES OF CHILDREN 



ample to differentiate this form of amentia from that associated with 
traumatic cerebral palsy. Besides, in paralytic amentia of natal origin, 
congenita] stigmata of degeneration (q. v.) which almost invariably pre- 
vail in microcephalus, and the "idiotic grunt" — the gutteral noise which 
the microcephalic usually exhibits particularly when he is enjoying a 
square meal — are usually absent. Finally, it is well to bear in mind 
that "sugar-loaf" head (oxycephaly) is occasionally met with in per- 
fectly normal children. 

Hydrocephalus" 

The pathologic anatomy in hydrocephalic amentia varies greatly 
with the quantity of cerebrospinal fluid in the cranial cavity, the 




Fig. 210.— Hydrocephalic idiot. 



period of its appearance and the length of time it has continued to 
exert pressure upon the vital structures of the brain. Thus do we 
find that in cases of postnatal hydrocephalus where the pressure hap- 
pens to be slight and temporary, the pathologic alterations in the brain 
are often insignificant, whereas in marked congenital hydrocephalus 



For "Acquired, Acute and Chronic Hydrocephalus," see p. 596. 



AMENTIA 711 

postmortem examination usually reveals considerable atrophy of sev- 
eral parts of the brain. The brain markings are generally effaced, the 
ventricles distended and their contiguous structures compressed and 
degenerated. The meninges are thin and bulging, the cranial bones 
greatly atrophied, and the fontanelles and sutures widely gaping with 
Wormian bodies freely distributed in the intervening spaces. Not 
rarely hydrocephalus is associated with spina bifida — undoubtedly 
Nature's attempt to relieve the excessive intracranial pressure (Fig. 
210). 

The most striking physical sign of hydrocephalic amentia is the ex- 
traordinary size and shape of the head. The head is usually asym- 
metrical, twisted in appearance (plagiocephalic), but may be rounded, 
egg-shaped (brachycephalic), long and narrow (dolichocephalic), or 
keel-shaped (scaphocephalic). The circumference of the head ranges 
between 22 and 30 inches or more. The scalp is very thin and barely 
covered by fine hair and traversed by conspicuous veins. The cranial 
bones are soft and often yield to light pressure with the finger, im- 
parting the sensation of parchment. In severe cases the orbital plates 
are pushed downwards while the eyeballs protrude forward, so that 
the lids are more or less retracted, leaving a ring of the sclerotic ex- 
posed. This anomaly gives rise to the peculiar staring expression of 
the eyes which is characteristic of the hydrocephalic idiot, and is es- 
pecially pronounced when accompanied by strabismus and nystagmus. 

The mental symptoms are not invariably correlated to the size of 
the head, some infants with huge heads occasionally possessing more 
intelligence than those with proportionately smaller heads. And if, 
perchance, the hydrocephalus is arrested before permanent damage to 
the brain has been wrought, the hydrocephalic may yet groAv up with 
a fair degree of mental capacity. Ordinarily hydrocephalic aments 
are quiet, gentle, timid, sorrowful and affectionate, and but little im- 
pressionable or curious. Owing to impaired function of the extremities 
by paraplegia and spasmodic contractures of the arms, they are rarely 
able to walk about and to help themselves, and when, as is often the 
case, vision (optic atrophy) and hearing are affected, they usually re- 
main infantile for life — which latter, fortunately is very rarely of long 
duration. Occasionally, hydrocephalus is associated with adipositas 
(Fig. 171), which most probably occurs in consequence of interference 
with the functional activity of the hypophysis cerebri. 

Chronic hydrocephalus may be confounded with rachitis, syphilis 
and macrocephalus in connection with hypertrophy of the brain. In 
rachitis the extremities are weak but neither paralyzed nor rigid, while 
mental deficiency, if present, is but slight; in hydrocephalic amentia 



712 DISEASES OF CHILDREN 

the reverse is the ease. The rickety head never attains the size of that 
of the hydrocephalic, and the cranial bones rapidly assume their nor- 
mal consistency upon removal of the cause of rickets, i. e., on attention 
to hygiene and proper nutrition and administration of lime and phos- 
phorus. In rachitis we usually find that in the first few months of its 
existence the child's physical and mental condition was normal, 
whereas in hydrocephalus there is a history of the presence of all of 
the aforementioned symptoms from birth on, or their sudden develop- 
ment in connection with some serious acute affection, especially tuber- 
culous or cerebrospinal meningitis (q.v.). Moreover in these cases 
the child rarely escapes severe involvement of the eyes and ears. In 
syphilis the head is not rarely greatly enlarged, but instead of being 
unusually soft it is often hard and bossed. Of course, where the 
syphilitic is also suffering from hydrocephalus, which is not at all 
uncommon (Fig. 137), the differential diagnosis between these two 
forms of amentia can be made only by means of Wassermann reac- 
tion, which should at any rate be employed from a therapeutic point 
of view. The following suggestions will prove helpful to differentiate 
hydrocephalus from macrocephalus associated with hypertrophy of 
the brain. 

Hypertrophy of the Brain Hydrocephalus 

The cranial bones are usually normal in Usually the reverse 

consistency: the enlargement develops 

slowly 
Marked pulsation at the anterior font an- Slight, if any 

elle 
Sutures slightly disconnected Widely gaping 

Ordinarily normal mentality or only Idiocy as a rule 

slight deficiency 
Slight intracranial pressure— if the foil- Very marked 

tanelles are open 

Paralytic Amentia 

(Vascular, Inflammatory, Toxic, Meningitic, or Epileptic Amentia) 
Under this heading are generally grouped the numerous cases of 
mental deficiency which are due to more or less extensive lesions in the 
brain occurring either before and during birth of the child or in the 
course of his first few years of life. The cerebral lesions may be the 
result of hemorrhage or inflammation, or both, accompanying prenatal, 
natal or postnatal cranial traumatism, asphyxia neonatorum, meningi- 
tis, encephalitis, influenza, measles, scarlet or typhoid fever, pertussis 
and similar microbic affections, and neoplasms. In the great majority 



AMENTIA 713 

of these cases the cranial bones are reduced in thickness, the meninges 
are adherent, and some of the convolutions are compressed, atrophied 
and indurated. Some portions of the brain are in a state of softening, 
others are found to have undergone cystic degeneration, cicatricial con- 
traction and sclerosis. The lesions are productive of variable clinical 
pictures in different individuals. They may lead to paralysis in one 
child, convulsions in another, and to amentia in the third, or to all 
these manifestations in one and the same child. Moreover, these phe- 
nomena are not invariably correlated to the extent of the lesions. And 
one is occasionally surprised to find diffuse lobular sclerosis of the 
brain with extensive blood cysts and porencephaly in a child who dur- 
ing life was apparently endowed with fairly normal mental faculties, 
and, conversely, only minute cerebral lesions with total idiocy. As a 
rule, however, in infants any seemingly trivial intracranial accident 
is followed by mental deficiency, hemiplegia or diplegia, and this is 
especially the case with lesions in the frontal, prefrontal and parietal 
lobes. 

Of 55 cases of hemiplegia examined by Sachs and Peterson, the men- 
tal impairment was feeblemindedness in 16 children, imbecility in 31, 
idiocy in 7 and epileptic insanity in 1 case. In diplegia the percentage 
of mental deficiency is always very high, between 60 and 75, whereas 
in cerebral paraplegia, which condition is usually associated with less 
extensive lesions, the mental deficiency is rarely very pronounced. 
Epilepsy, especially of the Jacksonian type, is quite a common sequel 
of cerebral hemorrhage or inflammation and ultimately ends up with 
progressive amentia. 

In order to obtain a clearer conception of the symptom complexes that 
usually follow the aforementioned pathologic alterations in the brain, it 
is advantageous to classify these cases in three large groups, in accord- 
ance with the time of their development, either before, during or after 
birth. The first group usually reaches this world in a more or less ab- 
normal physical condition. These children are often prematurely born, 
emaciated and disfigured, and of very low vitality. The head is either 
small and asymmetrical or normal in size, but soft and flattened on one 
side. The extremities are either rigid or slightly movable, or there may 
be mono-, para-, or diplegia. (See Fig. 211.) As these symptoms are 
the result either of arrested development of the brain or cord, or of 
both, or hemorrhagic or inflammatory processes therein, it is not at 
all uncommon to find several cranial nerves implicated. Under these 
conditions, of course, the diagnosis of congenital paralytic amentia 
is self-evident. The second group is generally described as Lit- 
tle's disease, or diplegia or paraplegia spastica infantilis. (See 



714 



DISEASES OF CHILDREN 



p. 615.) In the great majority of these cases there is a history 
of natal traumatism, asphyxia, convulsions immediately after birth 
and other signs of acute cerebral involvement. (See Pig. 213.) 
These cases, in addition to the characteristic physical syndrome, fre- 
quently present mental deterioration, ranging from simple feeble-mind- 
edness to total idiocy, and are often accompanied by stammering, 
nystagmus, strabismus, athetosis and epileptic convulsions. The third 
group of cases gives a history of apparently normal physical and mental 




Fig. 211. — Paralytic idiot of antenatal origin. 



development at birth, and of an acute or insidious onset of some febrile 
or wasting disease, or of traumatism some time after birth, which was 
later followed by amentia with or without paralysis or epilepsy, and 
often by degeneration of the cranial nerves. The mental impairment is 
usually progressive in character, and in older children may not be 
fully recognized until several months or years after the accident or 
termination of the primary affection. To this group of cases, encephali- 
tis and meningitis and their prolific sequelas, more especially partial or 



AMENTIA 



715 



total deaf -mutism and blindness, contribute the greatest number of 
victims, although traumatism with its great tendency towards epilepsy 
is exceedingly conspicuous in the histories of postnatal amentia re- 
corded. According to Fletcher Beach, other infectious diseases, such 
as typhoid, scarlet fever and measles do not form very rampant causes 
of this variety of amentia, for after examining the history of 2,000 cases 
of idiocy, imbecility and feeble-mindedness he found only 37 (or 1.85 
per cent) which could be traced to an attack of one of those affections. 
In connection with paralytic amentia it is opportune to call attention 
to a form of mental backwardness which is occasionally encountered as 
a result of hereditary syphilis. As has already been stated the amentia 
may appear in consequence of hydrocephalus or in connection with 




Fig. 212. — Paralytic amentia in consequence of cerebral hemorrhage during in- 
strumental delivery. The baby died at the age of two and one-half years from 
miliary tuberculosis. 



mono-, hemi-, or diplegia consecutive to syphilitic meningitis or en- 
cephalitis. More rarely the foundation to the amentia is estab- 
lished during intrauterine life in the form of gummatous infiltration 
and sclerosis of the brain. In this event the child is born with all the 
symptoms corresponding with the primary lesion in the brain, e. g., 
paralysis, defective vision or hearing, or involvement of other cranial 
nerves. Except for the history of the case and the positive Wasser- 
mann reaction there is practically no way of distinguishing syphilitic 
from nonsyphilitic paralytic amentia. However, irregular enlarge- 
ment of the head, particularly Parrot's nodes, should serve to arouse 
our suspicion. 



716 DISEASES OF CHILDREN 

Amaurotic Family Idiocy" 

This form of amentia is based upon specific pathologic alterations in 
the brain. It is characterized by some degeneration in the cerebral 
white fibers throughout the course of the pyramidal tracts, in the inner 
capsule, crusta, pons and medulla, and also of the pyramidal tracts in 
the lateral as well as the anterior columns of the cord. Furthermore, 
the same changes are found also in the gray matter of the central nerv- 
ous system — in the cortex of the brain, in the cranial nerve nuclei, and 
in the gray matter of the spinal cord down to the lowest lumbar and 
sacral segments. Wm. A. Holden has further established the fact that 
the changes in the retina are identical with those in the brain and cord, 
and were due to a degeneration of the retinal ganglion cells. Hirsch, 
after a very exhaustive histologic examination of several cases under 
his care, concluded that not only are the cells of the cortex of the brain 
affected but the ganglion cells of the entire nervous system, the main 
features being a condition of chromatolysis and other degenerative proc- 
esses of protoplasm, combined with considerable swelling of the cell 
body and displacement of the nucleus towards the periphery of the cell. 
The neuroglia and the blood vessels are found to be perfectly normal. 

Like the pathology, the physical and mental characteristics are 
entirely pathognomonic. The apparently normally born and develop- 
ing infant begins to fail in strength as it reaches the age of six or eight 
months. Although not losing in weight, nay, sometimes even gaining, 
it is noticed that the baby is unable to hold up his head, to^sit erect, 
firmly to grasp objects placed in his hands, and even forcefully to suck 
on the nipple of breast or bottle. Simultaneously with the muscular 
atony the baby begins to lose interest in his surroundings, fails to smile 
when accosted and to follow bright objects to which his attention is be- 
ing directed — all indicating mental deterioration. "When the back- 
grounds of the eyes are examined a very peculiar retinal image is ob- 
tained. Namely, the maculae are cherry red in color and surrounded 
by large grayish white patches. The optic nerves are atrophied in the 
great majority of cases and there is often also strabismus and nystag- 
mus. These eye symptoms gradually lead to total blindness, and the 
muscular atony rapidly borders on paralysis. Hearing at first is hyper- 
acute, but in the later stages of the affection becomes obtuse. At this 
time also there is often inordinate "explosive laughter," difficult de- 
glutition and a marked tendency to recurrent convulsions. In one case 
I noted pronounced hirsuties over the greater portion of the body. Thus 
deprived of sight and partially of the sense of hearing, limp and lan- 



* Warren Tay described this affection in 1881 as a purely local inner eye disease, while B. 
Sachs, in 1887, recognized and described it as a distinct brain affection. 



AMENTIA 



717 



guid as a result of the ever increasing atony of its musculature, the 
helpless creature gradually loses all its other senses and, fortunately, 
also its life. This usually occurs before the child attains two years of 
age. More recently, Vogt has described a ' ' juvenile ' ' form of amaurotic 
family idiocy which begins to manifest itself at a later age and runs a 
more protracted course. Its identity with the "infantile" form of the 
disease, however, is not generally conceded. 




Fig. 213. — Amaurotic family idiocy in baby 14 months old. Note inability to hold 
up its head. (See also Fig. 207.) 




W 



Fig. 214. — Macular change (cherry-red discoloration) in amaurotic family idiocy. 

(After Tay.) 

As its term indicates, this form of amentia affects several members of 
the same family or those who are closely related, and shows a very strik- 
ing predilection for offspring of the Hebrew race, more especially of 
immigrants from Russia and Poland. This peculiar family predisposi- 
tion seems to confirm the view held by Sachs and others that amaurotic 



718 DISEASES OF CHILDREN 

family idiocy is due to a congenital arrest of development, although the 
"juvenile" form seems to point to a toxemic nerve degeneration of 
postnatal origin. 

In the early stages of the disease amaurotic idiocy may readily be 
mistaken for rachitis, but in this affection the pathognomonic amaurotic 
eye symptoms are absent and the mental deficiency, if there be any, is 
very slight. Furthermore, rachitis usually sets in more frequently in 
infants over ten months of age and the muscular atony of the trunk and 
spinal muscles is never so pronounced as to produce dropping of the 
head backwards. More difficulty may be experienced in differentiating 
amaurotic family idiocy from cerebral neoplasms, be they syphilitic, 
tuberculous or malignant. I recall a case of gliosarcoma of the pons 
affecting a one-year-old infant, that was under observation of several 
pediatrists and ophthalmologists of note and was diagnosed as incipient 
amaurotic family idiocy, none of them even suspecting the presence of 
a cerebral tumor. While in the latter affection optic atrophy is a com- 
mon symptom, there is never a cherry red discoloration of the maculae. 
Furthermore, in tumor the muscular atony, paralysis and convul- 
sions are most apt to be unilateral in the beginning, and gradually bi- 
lateral, while in the amaurotic all the symptoms are bilateral right from 
the start. In early infancy Mongolian and amaurotic idiocy have two 
cardinal symptoms in common — namely, protrusion of the tongue and 
general muscular atony, which may lead to errors in the diagnosis. In 
such cases an ophthalmoscopic examination is decisive. It will also be 
found that in amaurotic amentia the tongue protrudes but slightly and 
inconstantly, and is otherwise normal in appearance, the reverse being 
the case in mongolism. Furthermore, in the latter condition the hair 
is wiry and the hands are usually spade-like, and the mentality defi- 
cient from birth on. As has already been stated, in all cases of doubt 
an ophthalmoscopic examination should invariably be resorted to be- 
fore arriving at a positive conclusion. 

Mongolism 

Except for the proportionately undue smallness of the pons, me- 
dulla, and cerebellum in relation to the cerebrum as compared with 
those of normal babies, the central nervous system of the Mongolian 
idiot shows no characteristic lesions. As in other forms of amentia 
the brain is immature and its cells are imperfectly developed. With 
growth of the body as a whole the brain too attains a higher state of 
perfection, but is never capable of unfolding the faculties of normal 
intellect. Mongolism is frequently associated with anomalies of the 
thyroid gland (hence were formerly often described as "cretinoids"), 



AMENTIA 719 

and of the heart, and not rarely with general tuberculosis. There 
seems to be an etiologic relationship between mongolism and syphi- 
litic heredity. Sutherland, for example, has found a history of syph- 
ilis in 11 out of 25 cases of mongolism under his observation. 

This form of amentia was first described by J. L. Down in 1866, 
calling particular attention to the facial resemblance of the members 
of this group of idiocy to those of the Mongolian, Asiatic races, such 
as the Chinese, Calmucks and Malays. The typical Mongolian idiot 
has a small egg-shaped (brachycephalic) head, covered by smooth, or 
dry frizzly hair; small aquiline nose, which is bound laterally to- 
wards the eyes by distinct vertical or semi-lunar folds of skin which 
cover the inner angle of the eye (epicanthus) ; triangular nostrils: 
almond-shaped, slanting, often prominent eyes with speckled irides 
and eczematous eyelids, not rarely also ectropion; flat, usually flushed 
expressionless face, with high cheek bones; distorted ears; high nar- 
row palate; cracked more or less protruding tongue with markedly 
enlarged papilla? (later the so-called "scrotal tongue") ; and irregularly 
set, discolored teeth. The hands are flabby, clumsy, spade-like, and 
the thumbs are stubby (due to atrophy of the phalanges). In addition 
to these characteristics the Mongolian idiot generally presents marked 
laxity of the articulations, so that the tips of the fingers may be hy- 
perextended almost to touch the dorsi of the hands, and the feet may 
be brought up to the neck and ears while he is in a sitting posture. 
The little fingers are usually very thin and curved inward; the geni- 
tals ill-developed ; the skin is dry, rough and hairy, and owing to 
circulatory disturbances the Mongolian idiot often suffers from chil- 
blains and cracked lips which are kept raw by the dribbling saliva. 
He is seldom free from hypertrophied adenoids and their sequela?, i. e., 
nasopharyngitis, bronchitis or even recurrent pneumonia. The latter 
may possibly be also due to the frequently accompairying rachitis, more 
especially chicken breast, large abdomen and spinal curvature. 

Notwithstanding all their troubles, Mongolian idiots are of a happy 
disposition, placid and affectionate, and fond of music. For this 
reason parents often fail to recognize the abnormal state of their 
children, even though they note their general bodily weakness, more 
particularly their inability to sit erect, to stand and walk. At about 
two years of age these aments usually become more active, vivacious 
(always "on the go"), mischievous, full of grimaces and facial con- 
tortions — often misleading the parents to believe that they had out- 
grown their tardy development, and even to assume that their chil- 
dren were exceptionally bright. However, as time goes on, it is 
generally found that their mentality is practically at a standstill, that 



720 



DISEASES OF CHILDREN 



they can rarely understand when spoken to and much less are 
able to speak. It is not uncommon to meet with Mongolian idiots, 
two or three years old, barely able to repeat single syllables, to feed 
themselves even with the fingers (tendency to gobble down the food), 
or to respond to Nature's calls. As they get older they learn to walk 
and to make themselves understood, and after suitable training, to 
make themselves useful and to perform little acts for their personal 
comfort, but they always remain in a primitive mental as well as 
physical state of development; unreasonable, helpless, awkward and 
uncleanly, often acquiring vicious habits (e. g., masturbation) which 
help to undermine their frail constitutions. 

With this clinical picture in view, there ought to be no difficulty to 
distinguish typical mongolism from similar forms of amentia. Atypical 
cases, however, may be mistaken for cretinism, microcephalus and rachitis. 




Fig. 215. — Mongolian idiot of 23 months, Calmuck type. 



In microcephalus the idiocy is more pronounced, the head either 
very small or asymmetrical, and the ability to make free use of the 
extremities in grasping, standing and walking appears at a very much 
later age than in the Mongolian idiot. 

Mongolism differs from cretinism in the following particulars : 



Mongolism 
Skull brachycephalic 
Hair straight, or wiry and abundant 
Skin thin, hairy and mottled 
Face flushed, vivacious 
Eyes almond-shaped; epicanthus 
Tongue narrow, cracked 
Little finger curved inward 
Thyroid treatment of little benefit, if 
at all 



Cretinism 
Quite normal 
Fine and sparse 
Swollen " padded " 
Pale and apathetic 
Palpebral fissures horizontal 
Broad, swollen, pale 
Stumpy 
Very beneficial 



AMENTIA 721 

We can readily distinguish rachitis from mongolism by the fact 
that in this affection the head is more or less square, soft and covered 
by fine hair more especially along the occiput. The eyes are normal, 
the face is pale, the tongue is neither protruding nor cracked, and the 
fingers are normal in shape. Rachitis may delay the cerebral functions for 
a few months, but the powers of speech, perception and voluntary mo- 
tion are intact, and the mentality of the rachitic child rapidly im- 
proves with the amelioration of its physical condition. 

Finally, let me emphasize that a diagnosis of mongolism should not 
be based upon the infant's physiognomy alone, for occasionally we 
may be confronted by a baby of Mongolian ancestry who may be 
otherwise perfectly normal in body and mind. 

Cretinism, Myxidiocy 

Thyroid insufficiency though primarily not a brain affection sooner 
or later gives rise to degeneration of the central nervous system, 
more especially of the cortical cells. In congenital cases the cere- 
brum is usually considerably smaller than in normal children, and its 
convolutions are simplified; the cerebellum is asymmetrical and its 
laminae are reduced in number. It is not rarely associated with hyper- 
plasia of the pineal gland, the hypophysis and thymus gland, show- 
ing Nature's attempt to compensate the thyroid insufficiency by hy- 
peractivity of similar structures. Pathologically, we distinguish two 
forms of thyroid insufficiency which lead to amentia. 1. Athyreosis 
or absence of the thyroid gland which is generally a congenital anom- 
aly, but may exceptionally occur as a result of traumatism or acci- 
dental extirpation (cachexia thyreopriva). In congenital athyreosis 
the gland is frequently found replaced by cysts or other neoplasms. 
Occasionally degenerated (or healthy!) thyroid tissue is implanted 
in the base of the tongue. 2. Hypothyreosis or deficiency of thyroid 
gland which may be of antenatal origin (e. g., congenital goiter) or 
develop later as a result of disease or traumatism. To this group be- 
longs also the endemic form of goitrous degeneration of the thyroid 
which prevails especially in certain sections of Switzerland, Germany, 
Asia, England, Russia, Hungary and America, in shut-up valleys of 
mountainous districts, and is supposed to be due to some toxic sub- 
stances in the unboiled drinking water.* That goiter is not uncommon 



*Note. — This view has recently been disputed and a number of clinicians look upon endemic 
cretinism as an infectious disease. In this connection the report of A. Kutschera (Wien. klin. 
Wchnschr., No. 45, 1910) is of considerable interest. He relates that he found two dogs to 
develop cretinism who shared the bed of their mistress, a semicretin. One dog was completely 
idiotic, could not bark and reacted to nothing. It had dry, brittle, dirty hair, and milk teeth 
together with permanent teeth. After removing these two animals the author put in the 
cretin's bed a healthy four-months-old pup of healthy parents. After three months this pup 



rsi 



DISEASES OF CHILDREN 



in very young infants can be gathered from the statistics collected by 
Demme, who among 643 cases found 53 to be of prenatal origin, 37 
which developed in infants under one month of age, 59 between two 
and twelve months, and 35 between thirteen and forty-eight months. 
Postmortem examination discloses in cretinism marked alterations in 
the osseous system. The cranial bones are thickened, the diploe is di- 
minished, and, according to Virchow, the sphenobasilic suture prema- 
turely closed. The long bones are thick and short and often markedly 
deformed. As in other forms of profound amentia there is in cretin- 




Fig. 216. — Cretin from birth'; total idiot. Note "trident hand.' 



ism retarded development of the centers of ossification of the carpals 
and of the epiphyses of the metacarpals and phalanges. Section of the 
tubular bones usually shows an invasion of fibrous tissue from the 
periosteum in between the epiphyses and shaft, thus hindering the 
growth of the bones in length. Around the base of the epiphysis there 
is sometimes a sheath-like prolongation w T hich may even be ossified and 



developed a large head, and ten months later it became a full fledged cretin while the rest of 
the litter of the same parents who were not exposed to cretinic infection remained perfectly 
normal. A second animal of a large race, which could not conveniently occupy the same bed 
with the cretin, also developed normally. The author, therefore, believes that cretinism is 
transmissible by direct, close contact. 



AMENTIA 



723 



form a distinct cup around the epiphysis. But in contrast to what is 
observed in rachitis, there is no proliferation of cartilage cells near the 
line of ossification. The same overlapping or cupping of the epiphyseal 
cartilages is noted also in the ribs and innominate bones and in the 
scapulae. 

The physical and mental manifestations of cretinism vary greatly 
with the degree of thyroid insufficiency. Moreover, they set in at a 
later period in breast fed than in artificially fed infants, owing to the 
fact that during the first few weeks of life breast fed infants receive an 
ample supply of thyroid gland substance through the mother's milk to 
counteract their thyroid insufficiency. In acquired athyreoism the 
characteristic symptoms of cretinism usually appear gradually, but 
once the clinical syndrome is completed, it is practically alike in the 
prenatal as well as in the postnatal cases. The head of the cretin is 
either normal in size or slightly enlarged, flat and plump and set upon 
a thick, short neck. The fontanelles usually remain open, the forehead 





Fig. 217. — Normal at one year. 



Fig. 218. — -Same case as Fig. 217 pro- 
nounced cretin at eight years. 



is low, and the root of the nose is broad and sunken. The face is weak 
and senile. The eyelids and lips are edematous and the tongue is large 
and "swollen" and hence, ever protrudes from the half -closed mouth. 
The teeth are slow in coming and rapid in decaying. The abdomen is 
greatly distended, often marked by a large umbilical hernia. The ex- 
tremities are more or less deformed and the articulations thickened. 
The hands and feet are short and flabby. Cretins learn to walk late, 
and their gait is awkward and draggy. The skin is dry, waxy and 
doughy in consistency, and the hair is sparse and brittle. The body 



724 



DISEASES OF CHILDREN 



temperature is generally subnormal, and owing also to the ever present 
anemia, cretins are very sensitive to cold, notwithstanding their cor- 
pulent appearance. "Fatty tumors" are usually found in the supra- 
clavicular and axillary spaces. 

The intelligence of the infantile cretin, as has already been stated, 
varies with the functionating capacity of the thyroid gland. In con- 
genital athyreosis there is total idiocy (myxidiocy). Some cretins, the 
so-called semicretins, possess a fair measure of intelligence. They ap- 
preciate their surroundings, and are able to acquire a meager vocabu- 
lary which may be ample to make their urgent wants understood, or 




Fig. 219. — Same case as Fig. 218 four weeks after treatment with thyroid. 

even to reply to simple questions. On the other hand, where the thyroid 
insufficiency is marked, they never reach even this low state of mental 
development, and, on the contrary, get more stupid as they grow older. 
In the great majority of cretins, the special senses are implicated. 
Taste and smell are obtuse; hearing is defective and vision dull. The 
voice of the cretin is ordinarily husky. Like the hydrocephalic aments 
they are timid, gentle and unassuming, and if left untreated, they re- 
tain their childish behavior for life. 

One of the most characteristic features of cretinism is its marvelous 
improvement under thyroid feeding. After exhibiting thyroid gland ex- 
tract in one form or another for but a short time, the cretin is often trans- 



AMENTIA 



725 



formed from an uncouth, apathetic and clumsy little creature into a 
lusty, gracile and growing human being. Thus the blurred facial features 
gain youthful expression; the lusterless, withered hair takes on new 
life; the stunted stature shoots up to almost normal proportions, and 
the brutal stupidity gradually gives way to human intelligence. How- 
ever, this marvelous transformation lasts only as long as the thyroid 
medication is permitted to exert its wonderful influence. With dis- 




Fig. 220. — Same case as Fig. 21S ten weeks after treatment with thyroid. 



continuance of the treatment the cretin slowly but surely sinks back 
into his everlasting idiotic condition. 

Total athyreosis in the early stages and partial cretinism at any pe- 
riod of early childhood may be confounded with severe forms of 
rachitis and mongolism. The differentiation of the latter form of 
amentia from cretinism has already been discussed in connection with 
the former affection. (See p. 720.) In distinguishing cretinism from 
rachitis it is well to bear in mind that the latter may complicate the 
former disease. But in rickets the deficiency of intellect is slight and 
not progressive; the tongue is neither large nor protruding; the skin 
is soft and thin and not rough and edematous ; the hair is normal and bald 



726 DISEASES OF CHILDREN 

only in spots, especially over the occiput, whereas in cretinism the hair is 
brittle all over the scalp, and, finally, the rachitic baby learns to talk early 
and its voice is perfectly normal even though it may be weak. Rachitis 
complicated by congenital microglossia and adenoids may on very rare 
occasions lead to errors in the diagnosis, but careful inquiry into the 
history of the case and the exhibition of thyroid extract will soon clear 
up all doubts. Furthermore, it will generally be found that in con- 
genital macroglossia the tongue gets gradually relatively smaller as the 
child's mouth grows larger, which is not the case in cretinism. Besides, 
there is always the marked difference in the physical and mental de- 
velopment of these children. 

Infantilism 

Under this heading are generally grouped several types of abnormal 
infants who never attain the physical and mental development of adults 
and who retain several characteristics of infants and young children 
throughout life. In physiognomy and stature infantilism is closely 
allied to cretinism, and in many instances directly dependent upon 
thyroid insufficiency. Similar clinical syndromes have more recently 
been observed in connection with deficient functions of the thymus, 
adrenals, pancreas, and pituitary gland, and some observers claim that 
similar arrests of development occur as the result of systemic poisoning 
by the syphilitic germ and other microorganisms. In accordance, there- 
fore, with the aforementioned etiologic factors, infantilism may be 
classified in the following types: 

Thyroid infantilism, 
Thymus infantilism, 
Pituitary infantilism, 
Heredosyphilitic infantilism,! 
Dystrophic infantilism, 
Cardiac infantilism, 
Intestinal infantilism, 
Malarial infantilism, 
Pellagra infantilism. 

Two special types of thyroid infantilism are generally encountered — 
namely, typus Brissaud, which is characterized by fullness of the 
face, plumpness of the body and clumsy extremities (Fig. 221), and 
typus Lorain whose stature is gracile and whose facial features are 
pleasant and comely (Fig. 222). 

The subject in question is as yet awaiting considerable elucidation. 
With the advance of our knowledge of the normal and abnormal 
actions of the ductless glands, w r e shall undoubtedly be able to clas- 



fl recently saw a case of this type weighing only 29 pounds at nine years. 



AMENTIA 



727 



sify infantilism in two large groups, thus: Genuine infantilism, em- 
bracing all cases in which mental deficiency predominates, and a 
second form of infantilism, which is being described as microsomia, 
nanosomia, ateliosis, asthenia, achondroplasia and Herter's infantilism, 
in all of which physical arrest of development predominates. I may 
state, by the way, that contrary to what is frequently recorded in 





Fig. 221. — Infantilism, Brissaud type, 
six years old; measures 32 inches in 
length. 



Fig. 222. — Infantilism, typus Lo- 
rain, four and one-half years old; meas- 
ures 32 inches in height and weighs 28 
pounds, acts like a two-year-old infant. 
Xote absence of left thumb and rudi- 
mentary development of right thumb. 



medical literature, so-called Herter's infantilism is not associated 
with actual mental deficiency. To quote this author: "The intelli- 
gence of these patients was in every instance good, although the ne- 
cessity of living very carefully and obeying the directions of the 
physician and nurse has tended to make these children somewhat 
introspective as regards their own ailments and to form the basis of 



728 



DISEASES OF CHILDREN 



what might with increasing consciousness develop in after life into 
a hypochondriacal condition." 

Congenital infantilism like congenital idiocy in general is often as- 
sociated with physical stigmata of degeneration. Atrophy of the 
genitalia is particularly common where the ductless glands are in- 
volved. (See Frohliclrs Syndrome, p. 570.) As in the idiot, we often 
find retarded development of the carpi also in infantilism. (See Fig. 
223.) The mentality of these children is very variable and depends 
entirely upon the period of life at which their mental development 




Fig. 223. — Left, wrist of ament 10 years old; right, wrist of normal child six years 
old. Note greater number of carpi in the latter. 



has been arrested. As a rule, they are never totally idiotic, and the 
majority of them are able to help themselves, to walk about and to 
play, and to understand a simple conversation. Speech is usually de- 
layed, but with advancing age and proper training, they ordinarily 
learn to speak, as well as to count, to write, and to earn a modest live- 
lihood. 

Moramentia* 

(Retarded Mentality) 

Delayed mental development is quite frequently the result of the 
following causes: (1) Deprivation of special senses, e. g., sight and 
hearing; (2) chronic affections, such as heart disease, and other severe 
nutritional disturbances; (3) faulty environment and education, or 
isolation. 



*For this group of cases mora-mentia would be a very appropriate term ; mora (ae) signify- 
ing delay, impediment, hindrance, and mentia being used to designate mentality. 



AMENTIA 



729 



Sense deprivation as a cause of retarded mentality need not be com- 
plete. Mere errors of refraction, for example, by leaving the child ig- 
norant of numerous objects outside its field of vision, may be entirely 
sufficient to delay the unfolding of its mental faculties. Similarly do 
we find that an infant afflicted with adenoids, which interfere with acute 
hearing and render it listless and inattentive, at least temporarily fails 




Fig. 22i. — Moramentia in a two-year-old boy, as a result of marked adenoids with its 
consequences, especially difficult hearing. 

to receive the outside impulses to the brain and hence remains mentally 
backward. These children, however, are not suffering from amentia in 
the true sense of the word. On the contrary, experience teaches that 
just as soon as the retarding elements are removed, e. g., removal of the 
adenoids and correction of the visual defects, the supposedly mentally 
deficient children rapidly reach a normal state of mental development. 



730 DISEASES OF CHILDREN 

Defective vision, particularly if congenital in nature (e. g., congenital 
cataract) or acquired soon after birth, forms a greater impediment to 
normal mental development than a similar defect in the sense of hear- 
ing. It is quite common to meet with very intelligent deaf-mutes who 
by means of lip-reading or dactylology even in early childhood are able 
to make themselves understood and fully to express their wants. 
Very recently two deaf-mutes, brother and sister, came under my ob- 
servation, who for intelligence could pass muster as any normal children 
of the same ages. Their parents were first cousins, and their father 
was fifteen years older than the mother. The little girl was eight years 
and the brother two years old. They had another brother, who was 
able to hear and to speak, but died at the age of five years during an 
attack of pneumonia. It was a most pathetic sight to watch the two 
children by means of dactylology and lip-language to converse among 
themselves or with their mother, and it was astonishing how much in- 
formation the mother was able to convey to the little baby. The older 
child was full of life and possessed of powers of observation and imagi- 
nation rarely to be met with in perfectly normal children of her age. 
While examining her she was intently interested in everything I was 
doing, and as I was testing her hearing — hoping possibly to detect a 
trace of it intact — she concentrated her whole mind upon the test, and 
off and on gleefully announced to her mother that she was capable of 
hearing — poor child, she was carried away by her vivid imagination ! 
And I shall never forget her literally shining face and the grateful, 
almost overflowing eyes, when, to please her, she was assured, that her 
condition was not hopeless, and that it was merely a matter of time 
when she would learn both to hear and to speak. 

The mental deficiency encountered in children suffering from some 
chronic organic affections or nutritional disturbances (e. g., rachitis), 
like that associated with the aforementioned deprivation of the senses, 
is only relative in character. In those children the brain possesses every 
potentiality for normal growth and development, but remains in a state 
of passivity for want of prerequisite outside impressions. This is due 
to the fact, on the one hand, that sickly, depressed children are not at 
all inclined to bother with what is transpiring around them, and, on the 
other hand, parents justly refrain from burdening sickly children with 
any sort of training and education. That deficient or disturbed nutri- 
tion, per se, is not a potent factor in the production of amentia, can 
readily be proved by watching the acuity of perception of emaciated 
so-called marasmic babies. Nothing that bears a semblance of food or 
its container escapes their attention, and they show a wonderful dex- 
terity in manipulating the nipple or bottle at a very early age. 



AMENTIA 



731 



Faulty environment and isolation, similar to deprivation of the senses, 
greatly retards mental elaboration owing to lack of cerebral impres- 
sions by outside influences. We can hardly expect a young child to 
distinguish objects it never had a chance to see or to touch; and the 
unfortunate child who happens to be cursed with a habitually intoxi- 
cated father, mother or both, and daily sees before him smashed heads 
and smashed dishes, and hears profanity on the one hand and incohe- 
rent babble on the other, is certainly ill prepared to acquire the attri- 
butes of normal mentality, and to show affection, power of imagination, 




Fig. 225/ — Moramentia, as a result of isolation and faulty environment. 



judgment and discrimination. Fault}' environment and isolation are 
not invariably the sad lot of the children of the poor and the degenerate. 
I have met with many a baby of fashion under two years of age or 
older, who at first impressed me as being utterly idiotic and who had 
remained mentally backward for several months thereafter, because of 
their having been secluded in some remote corner of their nurseries or 
huddled away under the upholstered hood of their carriages, and thus 
were given no opportunity to exercise their musculature or brain matter. 
Only too often do Ave see infants of the rich entrusted to the care of 
some inexperienced, half-baked, "white linen nurse," who considers it 



732 DISEASES OF CHILDREN 

her greatest achievement to keep the baby's bowels regular and who has 
not the slightest conception of the importance of early mental develop- 
ment. But as has previously been stated, this group of mentally back- 
ward children of the poor as well as of the rich, when by Nature en- 
dowed with normal brains, with marvelous celerity, they retrieve the 
dormant mental faculties if placed in desirable surroundings and given 
the benefit of sensible management. 

Prophylaxis 

The aforementioned theoretic consideration of idiocy and the allied 
mental deficiencies in childhood tend greatly, I believe, to establish the 
facts, first, that amentia is preventable in a large proportion of cases, 
if prophylactic measures are instituted early; secondly, that under 
suitable management a great many mentally deficient children can be 
made useful to themselves and possibly also to the commonwealth. We 
shall now endeavor to offer a few practical suggestions to accomplish 
this highly desirable object in view. 

One of the most essential factors in the prevention of mental debility 
in the offspring is their inherent bodily and mental strength. Inherent 
strength is not procurable after birth. As stated it is a consummation, an 
inheritance of ancestral virility and vigor, premarital purity, conjugal 
devotion, matrimonial chastity, sobriety and ideal hygiene. It can be 
fostered by sensible regulation of marriage, conservative mutual selec- 
tion, avoidance of consanguineous mating and prohibition of marriage 
among those encumbered by chronic brain affections, grave wasting 
diseases, alcoholism, drug habits and extreme poverty. Above all, in- 
herent strength can be fostered by judicious management of pregnancy, 
labor and the physical and mental care of the infant. Within recent 
years there has been a great awakening to the importance of exacting 
from those destined to procreate the race of the future that they be 
free from all encumbrances, congenital as well as acquired, which tend 
to embarrass their offspring in their normal development. And while 
eugenics, as at present taught, carries with it a good deal of useless, 
nay harmful, fiction and fetichism which veil its true object and render 
it subject to ridicule and derision, there is every reason for the belief 
that after the noisy agitation has ceased and thorough sifting of the 
good from the bad has taken place, the world will be very much the 
better for it. In the meantime, or until the lustrous millennium has 
dawned upon us, it is entirely sufficient for physicians to preach practi- 
cal rather than theoretic eugenics and to counsel those encumbered 
by grave hereditary taints to be very cautious in the selection of their 
mates, lest doubly marred heredity may intensify the degeneracy in the 



AMENTIA 733 

offspring. All agree that those suffering from specific venereal disease, 
tuberculosis, malignant disease, epilepsy and insanity are not marriage- 
able subjects, and should not be permitted to marry, unless they can 
show that they have remained free from any traces of these affections 
for a number of years. But it is not in the province of the physician to 
join the eugenists in their hunt for ' ' desirable types ' ' of man- or woman- 
hood, even were such types at all desirable. "What the eugenists set 
up as desirable types," says A. C. Jacobson, "strikes many of us as 
merely smug, unctuously respectable and commonplace paragons. If 
the eugenists had their way and succeeded in peopling the world with 
a race of disgustingly normal beings, standardized to the Philistian 
scale which the intellectual plebeians who are so warmly drawn to- 
wards the eugenic camp seem determined to devise, life w T ould be 
drab and jejune indeed. Happily such a consummation can never be, 
for which the gods be thanked. Anything approaching real control 
of the race after the plan of these fanatical breeders is a phantasy 
* * * since haphazard ' scrub-breeding' has gone on in the human 
family so long that pure strains with definite character units are 
practically unknown. Hence, who is the fit? What is fitness"? 
Physicians can do most good by judicious management of pregnancy 
and labor, and the rearing of the child, more especially during its first 
few years of life. As has already been stated, after impregnation the 
destiny of the offspring is partially or wholly dependent upon the 
physical and mental welfare of the mother. "But even if it be proved 
— it has not yet been proved — that the conditions of life in the nine 
months before birth have no influence either for good or ill upon hered- 
itary maladies and deformities, even then there remains much to be 
done in antenatal hygiene, for there cannot be the slightest doubt that 
many morbid influences come to play upon the body of the infant in the 
womb and that some at least of them may be prevented or their results 
cured" (Ballantyne). No definite statistics have thus far been ad- 
duced to show the degree or extent of the beneficial influence of ante- 
natal hygiene upon the mentality of the offspring, but some approxi- 
mate estimate can be obtained by analogy, when we compare the weight 
and physical power of resistance of babies born under favorable condi- 
tions with those born of mothers who up to the last moment of preg- 
nancy were exposed to hardship and struggle for existence. Thus, Pinard 
gives as the average weight of babies of women, who worked up to the 
time of delivery, about 6% pounds, while for those born of women, who 
had a short respite from hard work before delivery, l 1 /^ pounds. Borde 
found the average weight of babies of Italian women, who worked up 
to the delivery, to be 6!/4 pounds, while of those, who had rested a few 



734 DISEASES OF CHILDREN 

weeks before delivery, about 7 pounds. More recently S. Peller re- 
ported bis findings among Austrian women. His material was drawn 
from two sources, a sanatorium for women of means with 612 patients, 
and a large clinic for poor women (under the direction of L. Teleky) 
with 4,875 cases. He found that the first born male babies of well-to-do 
women averaged about 4 ounces heavier and the female babies about 3 
ounces heavier than the babies of poor women who worked up to con- 
finement. Moreover, in a comparison of the first born children of 
hospital women with those of the women coming to the hospital just 
before confinement, the babies of the former are shown to average about 
4 ounces heavier than those of the latter group. 

"With these observations in view the importance of antenatal hygiene 
for the betterment of the race of the future becomes self-evident. The 
prospective mother should be placed in a wholesome environment and 
proper hygienic surroundings. Her diet should be liberal, her living 
rooms spacious, and airy, and her association cheerful. Wherever possi- 
ble, she should be free from the anxieties of earning a livelihood or the 
pompous frivolities of wanton society. The boundless extravagancies 
of extreme wealth and the awful misery of extreme poverty, both alike, 
sap the vital forces of the mothers as well as of their offspring. The 
State, if need be, should provide for the poor expectant mother at least 
a few weeks' respite from hard work previous to delivery and also 
thereafter. We must allay the anxiety of the primapara by assuring 
her that pregnancy and parturition are physiologic, normal processes, 
under proper management devoid of perilous complications and sequelae; 
and the multipara should be impressed with the fact that miscarriages 
and attempted . abortions are dangerous experiments, one tending to 
interfere with normal development of the offspring that are to come 
later (by leaving the uterus in a more or less permanently diseased 
state), the other actually injuring the embryo or fetus during the proc- 
ess of growth and development. 

Next to antenatal hygiene the judicious management of labor serves 
as the most important means in the prevention of amentia in the off- 
spring. Judging by the appalling number 1 of cases of paralytic amentia 
following traumatism during birth, and considering the fact that the 
cases recorded form but an infinitesimal portion 2 of the innumerable 
cases that never see light after delivery or survive the injuries sus- 
tained but a few days or weeks, there must be something very seriously 



il^apage reports 25 out of 96 cases of amentia under his observation; Still 26 out of 135; 
my own records show 30 cases out of 119. 

2 In Philadelphia, for example, out of 39,975 births during the year of 1911, 2,131 were still- 
born; and according to the annual report of Miss Julia C. Lathrop, out of 300,000 infants under 
one year who succumbed during 1911, about 30 per cent did not live to complete the first 
month of life as a result of prenatal conditions or of injury and accident during birth! 



AMENTTA 735 

wrong with the way midwifery is being practiced even in the civilized 
parts of the world. Dne allowance, of course, must be made to the fact 
that in this country the women who furnish the greatest number of 
births are of foreign birth and bringing up, and owing to mistaken 
prudery still cling to the custom of their mothers and depend upon ig- 
norant midwives for the performance of the vital function of obstetri- 
cian. But it is high time that each state or the Federal government 
should put a limit to this much abused "personal liberty" clause and 
insist upon only licensed midwives (after practical examinations) being 
permitted to practice obstetrics, in order to safeguard the future welfare 
of the children as well as of the mothers, not to speak of the economic 
benefits to their respective communities. Medical men also ought to 
awaken to the gravity of the situation, and, on the one hand, refrain 
from the hasty application of instruments in ordinary cases, and, on 
the other hand, in difficult labors not to hesitate to invoke the assistance 
of competent obstetricians, who through skillful manipulation might 
possibly be able to prevent cranial injury, asphyxia, etc. in the infant, 
which so frequently lead to cerebral diplegia with amentia. Pituitary 
extract, the most recent addition to the obstetrician's armamentarium, 
which in appropriate cases seems to exert an almost magical effect upon 
inertia uteri, will undoubtedly greatly help to dispense with instru- 
mental deliver}' and thus to diminish the number of aments due to this 
cause. 

As regards the postnatal care of the infant in the prevention of mental 
deficiency, let me urge upon physicians ever to remember that their 
sphere of usefulness does not end with the perfunctory manipulation 
of the stethescope or thermometer, nor even with the punctilious elabo- 
ration of food-formulas, diet lists or recipes. The mentality, das 
Sinnesleben, (the mind activity, or the senses) of the child should enlist 
as much of our deliberative attention as its physical condition, more 
especially when there is a tainted family history or an environment that 
is conducive towards a morbid mentality. And while it surely is the 
physician's paramount duty to safeguard the physical welfare of the 
child, it is no less important for us to guide its mental destiny. Indeed, 
strength of mind quite often compensates for weakness of the body, 
while strength of body only very rarely, if ever, compensates for weak- 
ness of mind. 

In the mental training of infants we usually meet with two extremes. 
One class of mothers keeps its infants in a state of noli me iangere, 
hidden in the remotest corner of the boudoir, lest it be bewitched by an 
"evil eye," or, as they say, unhinged by the premature sensitization of 
the brain; the other class of mothers injudiciously strains its infants' 



736 DISEASES OF CHILDREN 

cerebral functions to the breaking point, makes them the central figures 
of attraction of their household, teaches them to sing and to recite, to read 
and to write at a very tender age, when they are barely out of their 
bottling period. These two extremes in mental training should reso- 
lutely be discountenanced, and the happy medium chosen. The in- 
fantile brain, like the potter's clay, needs moulding while it is fresh and 
pliable, but it must be mastered skillfully and gently to avoid exhaus- 
tion of the brain cells or their disarrangement. The mental training 
should begin when the infant is about three months old. He should be 
picked up a few times a day, put on the lap and supported with the 
forearm, and shown a few lustrous things to stimulate his power of 
vision and attention. Gradually some object should be put in his hands 
to train him to grasp. As he gets a little older, he should now and 
then, for a few minutes at a time, and properly supported, be sat up in 
his carriage or bed, and allowed, as it were, to make a general survey 
of the beautiful world and the grand things that help to make it so. At 
six months of age, if strong enough, he should be put in a baby chair, 
given a few harmless little toys to play with, and be permitted to be ac- 
costed by some intimate friends of the family, in order to get the child ac- 
customed to distinguish strange faces. Some few months later, he should 
be gradually taught to perform some simple baby tricks, such as clap- 
ping hands, and the like. In suggesting these procedures I do not at 
all intend to convey the idea that every kin and friend of the family 
should be invited to exhaust their ingenuity to devise means to enter- 
tain the baby. Quite the contrary, we must ever bear in mind that an 
infant is easily fatigued, irritated and indisposed, and hence should 
not be overtaxed even by the simplest methods of training. This holds 
true also of older children, for many a supposedly nervous, naughty, 
intractable, listless or morose child, on careful inquiry, is found to be 
suffering from the effects of overtaxation of its mind by injudicious 
entertaining,, or training and education. 

On a previous occasion attention has been directed to the serious 
consequences, in the way of mental affections, not rarely following 
febrile diseases of childhood. Here also it is in the physician's province 
to educate the public that measles is not a "children's ailment that 
every child must go through," that whooping cough is not "harmless 
and makes children fat thereafter," and that "scarlet rashes" are "of 
no consequence and the result of a spoiled stomach or teething." And 
the sooner the people will appreciate that grave danger lurks even in 
the most benignly appearing attacks of infectious diseases, the sooner 
will the mental deficiencies arising from this cause dwindle down to 
insignificance. 



AMENTIA 737 

Active Treatment 

We can now pass on to the treatment of amentia, and since this 
chapter is intended for the discussion of mental deficiencies in infants 
and children under school age only, we propose to speak only of thera- 
peutic measures, (hygienic, pedagogic, physical, medicinal and surgi- 
cal) as they are applicable chiefly in the management of aments under 
five years of age. 

Hygiene 

An ample supply of fresh air and good food, bodily cleanliness and 
proper clothing are essential prerequisites ; in many respects more so 
in the care of aments than in normal children. Owing to the tendency 
of mentally deficient children to contract tuberculosis and the fre- 
quency of respiratory embarrassment as a result of nasal disease or 
deformity, they should be kept outdoors most of the day and in 
thoroughly ventilated rooms during the night or inclemency of the 
weather. This fact should strongly be impressed upon those who take 
care of these children, since most mothers are apt to mistake the cause 
for the effect and attribute the difficult breathing and nasopharyngeal 
catarrh to "catching cold" in the street. 

Several precautions have to be taken in feeding mentally backward 
infants. Some of them owing to their voracious appetite and lack of 
prehension of the sense of heat or proportion, are apt either to burn 
their mouths with hot food or swallow big morsels, and thus perma- 
nently impair their powers of digestion. In the majority of cases, 
therefore, it is required to prepare and subdivide the food properly, 
just ready for consumption. Others again because of an imperfect 
sense of taste and inability to manipulate the tongue, often refuse 
food, especially solids, and have to be fed with small quantities of 
food at frequent intervals. Owing to nasal obstruction, either as the 
result of adenoids, nasal deformities, or general debility, some con- 
genital idiots experience difficulty to nurse at the breast ; hence, it is 
often necessary to pump off the breast milk and to feed the baby 
either through a bottle and small nipple or by means of a spoon. As 
soon as possible, let us say from the eighth month on, mentally back- 
ward infants should be put on a mixed diet, in order to prevent 
rachitis or scurvy. We usually begin with small quantities of fresh 
fruit juice, beef juice, strained vegetable soups, coddled eggs, cereals 
with milk, stewed fruit and vegetable puree, gradually increasing the 
quantity of food as they get older, so that at the age of three or four 
years they can be put on the following dietary: 



738 DISEASES OF CHILDREN 

On rising in the morning, 4 ounces of milk, preferably boiled. 

One hour later, about 8 a.m., % ounce of orange, pineapple, or grapefruit juice; 
4 to G ounces of well-cooked cereal in milk and a little butter, e.g., oatmeal, farina, 
sago, rice, tapioea, cream of wheat or arrowroot; milk toast, and a coddled or 
poached egg. 

At about 12 m., 4 ounces of broth with some cereal or toasted bread; 2 ounces of 
vegetables (potatoes, carrots, spinach, cauliflower, beans, peas, etc.) well cooked 
and finely mashed; % ounce of finely chopped scraped beef, chicken or lamb chop, 
or boiled or broiled white fish. If the child is still hungry we may add a slice or 
two of stale bread and butter, divided into small pieces. 

At 4 p.m. one cup of boiled milk with a few biscuits with jelly or butter; or a 
ripe banana. 

At 6 p.m., one coddled egg, bread and butter or jelly, and 4 ounces of boiled 
milk; or cereal pudding or custard, bread and jam or treacle; or a cup of cocoa 
with toasted bread thrown in and a small portion of stewed fruit. 

Water should be given between meals. 

Before and after each meal the child's hands and face should be 
thoroughly washed as a routine procedure, which may aid also in 
teaching the child cleanly habits. 

The training of cleanliness is very essential to the child's future 
welfare, since it not only serves to make it more presentable to those 
coming in contact with it, but, which is by far more important, it 
acts as the most efficient preventative of divers local and constitu- 
tional infections. In addition to frequent local cleansing of the body 
as necessity arises, it should receive a tub bath daily, preferably in 
the evening, in the same manner as normal children. Kegardless of 
the mental condition of the child, every effort should be made to train 
him to respond to Nature's calls. From six months of age on he 
should be put on a nursery chair at regular intervals, at first every 
two hours and later every three or four hours. If his bowels do not 
move spontaneously after he has been sitting on the chair for several 
minutes, the infant should be trained to press by inserting into the 
rectum a small soap stick or glycerine suppository. After persistent 
training even the idiot will gradually learn to understand what is 
expected of him, when placed upon the nursery chair, and in time he 
will of his own accord announce his desire to urinate or defecate. 
Aments more so than normal children, should receive more care as 
regards changing of diapers and keeping the mouth, nose and eyes 
clean, in view of the fact that, as a rule, they are less sensitive to 
pain and annoyance, and hence are less apt to complain when those 
portions of the body are in an irritated state. Moreover, special at- 
tention should be paid to apparently the simplest kinds of cutaneous 
eruptions as these often serve as portals of entry to systemic infec- 
tions. 



AMENTIA 739 

Mentally deficient infants, especially if delicate and thin, should be 
very warmly dressed. They may suffer greatly from the effects of 
cold and yet fail to appreciate it, owing to dulness of sensibility. 
Chilblains and frost bites are quite common among them and general 
circulatory disturbances are frequently encountered, especially in 
Mongolians and cretins. Flannel and silk underwear should be given 
preference to cotton or flannelette. During the cold season special 
protection should be accorded to the hands, feet and ears, and very 
delicate infants may preferably be kept indoors, in well ventilated 
rooms, particularly if they show a marked tendency to congestion of 
the nasopharyngeal mucous membrane. 

"Incentive" Training 1 , and Physical Therapeutic Measures 

The main object of systematic training in amentia is to render the 
mentally backward child capable to help himself in the care of his 
body, to look out for his health and comfort, and later to learn some 
simple occupation to earn a livelihood. This requires first of all the 
ability to exercise the voluntary musculature. Since in a great many 
aments several groups of muscles are either atrophied and incapaci- 
tated from disuse or actually paralyzed, we must endeavor to estab- 
lish or reestablish their functions by passive motion, massage, hydro- 
therapy, electricity and active exercise. These procedures must be 
continued uninterruptedly daily for months and sometimes for several 
years, notwithstanding their seeming futility. In the end we are 
usually amply rewarded by success for our patience and perseverance. 
Even in the paralytic it has repeatedly been found that the function 
of the diseased cerebral area has been taken up by the corresponding 
healthy structures of the brain; and as has been shown by Vitzow, 
Pfitzner, Merk, Cattani, Klebs and others, in exceptional cases actual 
regeneration of nerve tissue occurs where its injury is not very pro- 
nounced. The physical treatment of the affected limbs should begin 
as soon as their weakness Or paralysis has been determined regardless 
of whether or not reaction of degeneration has supposedly taken 
place. For it is by far safer to err in the direction of overtreatment 
than undertreatment. Let me illustrate this point by a case under 
my observation. It concerns a three-year-old boy who received severe 
cranial injuries during instrumental delivery. The abrasions from 
the blades of the forceps were still visible six weeks after birth, when 
the child came under my care. There was at the time distinct paraly- 
sis of the face, of both upper extremities and of the right leg. A few 
days before, the baby was seen by a noted neurologist who thought 
there was no hope of his ever recovering, and discouraged further 



740 DISEASES OF CHILDREN 

treatment. The ease did look hopeless, yet the parents failed to 
reason as disinterestedly as the learned doetor did, and I also agreed 
with them that the baby ought to be given a chance to fight for his 
own. The facial paralysis proved peripheral in character and the 
paralysis of the left arm was of the Dnehenne-Erb type ; both disap- 
peared under massage, electricity and patience, while the right hemi- 
plegia has improved so much that the boy is able to walk about with 
ease and to participate in all sorts of children's games. Moreover, 
his mentality seems perfectly normal. I may add, by the way, that 
his cranial circumference measures about 22 inches, and by its shape 
and consistency gives the impression of a macrocephalus accompany- 
ing hypertrophy of the brain. 

There are a few practical points to keep in mind in the application 
of massage, electricity and hydrotherapy. The massage movements 
should consist of stroking, friction, kneading, light pinching, tapping 
and rhythmic vibration. The duration of each treatment should vary 
from a few minutes in the beginning up to a quarter of an hour after 
the child has become used to the manipulations. This should be fol- 
lowed by passive motion of a few minutes' duration. The massage 
should be gentle, preferably by means of talcum powder, since it al- 
lows the hands to glide smoothly over the body surface. 

Electricity should be administered from ten to twenty minutes at a 
sitting, either daily or every other day, using the mildest current that 
will cause muscular contraction without undue pain. The^ galvanic 
and faraclic currents, alternated with the sinusoidal, answer the pur- 
pose well. If single muscles or muscle groups are affected, the sponge 
electrodes are to be applied near or at the points of origin and inser- 
tion of the muscles, while if whole extremities are involved, we apply 
a large flat sponge electrode, well moistened in warm salt water, on 
the spine and stroke the affected muscles with a small electrode. 

Hydrotherapy is particularly useful in amentia associated with mus- 
cular rigidity and general cerebral irritability. A warm (98° F. to 
101° F.) tub bath, of from five to ten minutes' duration, should be 
given once or twice a day, and while the child is in the tub its limbs 
should be gently rubbed with a rough flannel and if possible extended 
and moved in all directions. 

Simultaneously with the application of these therapeutic procedures, 
we employ systematic training of the voluntary musculature and of the 
special senses, in order to foster the physical and mental devel- 
opment of the backAvard child. In pursuing this course of treatment 
we must as closely as possible follow the successive steps taken by 
Nature in the unfolding of the human intellectual faculties, and avail 



AMENTIA 741 

ourselves of the child's natural instincts to assist us in our efforts. In 
our study of the normal baby Ave have noted that immediately after 
birth he is endowed with the instinct of suckling, or "fishing" for 
food, and to cry when hungry or thirsty. This instinct is as strongly 
developed in the idiot as in the normal child. Now, then, since the 
struggle for food, for self-preservation, forms the ever and every- 
where dominating and propelling force of evolution in the animal 
kingdom of the entire universe, and has formed the most vital in- 
centive even in primitive man to devise ways and means for its 
sustenance and perpetuation, I believe that the irresistible force to 
quench thirst and to appease hunger ought to be sufficiently power- 
ful to awaken even the total idiot from his mental torpor, and to in- 
duce him. as it were, to struggle for his existence. Indeed, the longer 
I practice this incentive method of training of the mentally defective 
infant, the more convinced I am of its superiority over every other 
method of training in vogue. \Ve make use of his desire for food to 
teach him how to look, how to listen, how to pay attention, how to 
grasp, how to imitate personally and with objects, how to walk and 
how to talk — all in the order in which the normal baby acquires 
these faculties, except, of course, at greatly delayed periods as com- 
pared with the age of the normal baby. The sooner the training is 
begun, the more promising are the results, principally because in 
amentia of long standing the brain cells usually entirely lose their 
regenerative quality. This fact should strongly be impressed upon 
the unfortunate parents who rarely note any mental deficiency in 
their infants, and if they do, are often led to believe that they will 
"outgrow their weakness when they get to be seven years old." 

As amentia is very readily recognizable in an infant about six 
months of age. we proceed with the training in the following manner: 

1. If it is a nursing baby, he is put on the lap facing the mother 
or wet-nurse, and, after exposing the breast, the baby's hands are 
brought in contact with it and manipulated so as to make them grasp 
it. This is repeated for a few minutes before each nursing. AVe next 
bring the baby near the breast nipple and squirt a little milk in his 
mouth. As the baby puckers his lips to grasp the breast nipple, we 
promptly pull the child back, so as to force him to struggle to get a 
good hold of it. This also is repeated for a few minutes. If it is a 
bottle baby, we perform the same maneuvers with the bottle and 
nipple. As he gradually learns to recognize the bottle, we next en- 
deavor to train the baby to follow the course of the bottle by slowly 
moving it before his eyes in all directions, before allowing him to get 
hold of the nipple as it comes near his mouth. It may take several 



742 DISEASES OF CHILDREN 

days, weeks or even months to accomplish this trick, but patience and 
perseverance are the keynote to success in the training of the men- 
tally defective. 

2. After the baby has acquired the power of grasping the bottle, 
we place the child in a semirecumbent posture with the head resting 
on a small pillow, put the bottle in his hands, and as he is about to 
start to suck the nipple, we slowly pull the bottle backwards and 
continue to do so while the child is making every effort to bring the 
bottle to his mouth, and by hanging on to the bottle lifts himself 
from the recumbent to a sitting posture. This up-and down-movement 
is exceedingly useful to strengthen the arm- and spinal muscles and 
to train the child to raise himself from a recumbent posture. Of 
course, these exercises must be continued for several minutes before 
each feeding. 

3'. Like normal babies, aments also should receive a mixed diet 
when they reach eight or nine months of age. Most of them, as a 
rule, can be readily induced to take eggs and fruit, which are most 
excellent bone and brain builders. We hold the egg in front of him 
and feed him with a spoon at short intervals, making him wait for 
the next spoonful until he shows anxiety to get it. If a white egg 
does not attract his attention, we color it red or blue, and move it in 
different directions to teach him to follow objects. Similarly, hold a 
red apple in front of him, scrape some of it, and feed him^at short 
intervals ; bring the fruit near his nose and let him learn to perceive 
its odor. Some idiots have a highly sensitive sense of smell, and by 
using attractive odors as a bait, they can be induced to awaken from 
their apathy and to respond better to the systematic training. Next, 
place the child near the side of the crib and put his hands on the 
upper cross-bar, and while you hold the apple at a short distance 
above his head, with one hand, help the child to lift himself from his 
position with the other hand ; as he accomplishes it, let him have some 
of the apple, (orange or peppermint stick), and let him go through 
the same performances again and again to earn some more of it. 

4. By means of a rod and cord, suspend a red apple or orange in 
front of the baby, and let it hang there for a little while. If he re- 
mains passive, bring the apple near him and let him grasp, smell and 
taste it; if he is now attracted by it, swing the apple to and fro and 
encourage him to follow it with the hands and grasp it. Repeat the 
exercise several times and let him have some of the apple for each 
successful effort. Toys may be used instead of eatables where the 
child shows preference for the former. By continuing these exercises 



AMENTIA 743 

the child gradually gains considerable power of attention and muscu- 
lar coordination. 

5. Aments should early be taught to feed themselves. Sit him in a 
baby chair, if need be well supported with pillows, and place the food 
before him. Give him a taste of it, and if he is good and hungry, he 
will "fish" for more. In this event, if the food is solid (e. g., a zwie- 
back), put it in his hand and guide him repeatedly to bring it to his 
mouth. It is usually a very difficult task, to teach mentally deficient 
children to feed themselves, but hunger and persistent training will 
accomplish it in the end. 

6. To teach him to stand, we place him against the side of the bed 
with his arms crossing the top bar, and feed him with a spoon in such 
a manner that he is forced to raise his head to receive the food. In 
the beginning, it is usually required to support his back to keep him 
from falling. As he learns to stand, put him in a softly padded walker, 
the top of which snugly surrounds his waist. Keep the dish of food in 
front of him, give him a mouthful of it and take a short step back- 
ward; let him follow you (which in the beginning may call for your 
assistance) ; give him another mouthful and let him again push for- 
ward. Repeat this a few times a day, at first only for a very short 
time, in order not to tire him. A doll carriage may occasionally suf- 
fice as a support instead of a walker, especially after the child has 
partly learned to walk, and only needs additional exercise. 

7. Gradually train him to walk without any support. This is best 
accomplished first by standing him against a wall, and while facing 
him, let him grasp one of your index fingers, and follow you while 
you take single steps backward. Later extend to him a cane or rod 
instead of your fingers. If he hesitates to follow you, use some fruit, 
sugar or candy as an incentive, which you hold in front of him and 
reward him with for successful efforts. Or put his food on a Ioav 
table, direct his attention to it and lead him towards it, In time he 
will go after his food without being led. 

8. All the while the child is receiving instructions keep on telling him 
what you are doing and what you wish him to do, regardless of 
whether or not he understands you. Gradually he will learn to 
understand at least part of what you are telling him. Use single 
words instead of sentences, e. g., eat, drink, walk, etc., and repeat the 
words in a firm tone of voice, in order to make a lasting impression 
upon the auditory center. 

9. After he has learned the different exercises, you can begin to 
interest him in drills, tricks, and games as practiced in modern kin- 
dergartens. Almost all mentally deficient children are charmed by 



744 DISEASES OF CHILDREN 

music; it is therefore of great advantage to make use of harmonious 
si rains of the piano to arouse the dull child from his slumber and to 
soothe the discordant impulses of the agitated child. Different strains 
of music should be used for different sets of actions, in order to train 
the child's auditory apparatus to connect the particular melod\ T with 
the particular act he is to perform; in other words, one and the same 
melody with his meals, another one when he marches, a third when 
he plays a certain game, etc. Music should be employed also in 
training him to speak. Thus, while playing the piano sit the child 
in front of you, attract his attention to your mouth, and, with a tone 
of voice corresponding to the strains of music, keep on repeating 
single syllables or words, e. g., ba-ba for one melody, la-la for another, 
ta-ta for a third and so forth, gradually lengthening the syllables into 
whole words. In speech, as in other exercises, its accomplishment is 
often facilitated by using food as an incentive, i. e., give him a piece 
of candy every time he makes an earnest effort to pronounce certain 
syllables or words. 

10. Imitation is the mother of experience. Teach him to imitate 
your personal movements, such as kneeling, sitting, standing, opening 
and closing of the mouth or hand, throwing a ball or catching it, and 
similar exercises. 

11. Sit the child near a table facing you ; spread out in front of 
him some candy or some other eatable he is fond of, and let him taste 
some of it. If he likes it, he will surely look for some more of it. 
Now cover the remaining pieces of candy with a strip of paper, leav- 
ing part of it exposed. If he shows ability to remove the paper and 
to help himself to the candy, put the latter in a little box, first with- 
out a cover and then with a transparent cover. Now teach him to un- 
cover the box, and, if he succeeds doing it, reward him with a piece 
of candy. Next put the candy in a more complicated contrivance, and 
the more ability he shows to help himself, the more difficult should it 
be made for him to find the thing he is looking for. By repeated 
training he will gradually learn to help himself in many other re- 
spects. 

12. Place the child in front of a step ladder and put the candy on 
one of the rungs and encourage him to reach for it. Of course, at 
first he will need your help. As he ascends the ladder, hand him a 
piece of candy. Eepeat this maneuver again and again, and as he 
succeeds in getting there, elevate the box to a higher level. In a 
similar manner reverse the performance, i. e., make him descend in 
order to reach the box. As he learns to accomplish this with ease, 



AMENTIA 745 

teach him to el hub stairs, first by supporting himself with the hands 

and later by doing it without support. 

The performances, of course, can be multiplied almost ad infinitum. 
But there are two essential ideas ever to be kept in view in the train- 
ing of aments — namely, first, no coercion or force is to be applied; 
second, no time and energy should be wasted on exercises which are 
not absolutely indispensable to his welfare. If Ave succeed in training 
a deficient child under five years of age, to be clean, to feed himself, 
to walk, to understand words spoken to him and. possibly, to make 
himself understood, even if only by single words, enough indeed will 
have been accomplished. By opening up the avenues of approach 
to the dormant, deficient infantile brain, the brain itself will spon- 
taneously evolve its resourcefulness, round out the experience, and 
receive new impressions. 

In suggesting the aforementioned exercises I presume, of course, 
that Ave are not dealing with total idiocy accompanying extreme de- 
grees of hydrocephalus, microcephalus, diplegia, etc., or amaurotic 
family idiocy. In these cases no amount of conscientious training 
ever will bear fruit in restoring degenerated brain tissues to normal 
function. Moreover, the span of life of these unfortunates measures 
but a feAA T years. On the other hand, Avhen confronted by a mentally 
deficient child avIio is free from gross cerebral lesions and sIioavs some 
response to outside influences — for example, a child of tAvo years re- 
sponds to the mental tests for a normal baby of six months — pains- 
taking and persistent training will most assuredly bring forth A T ery 
gratifying results, eA'en though in the beginning nothing but failure 
will seem to croAvn our efforts. The late Edouard Seguin. one of the 
early pioneers in the training of mental defectiA^es, AAiien once asked 
why he kept on repeating the same moA^ements a hundred times a 
day, replied because the child does not make them right ninety-nine 
times. This Avas the secret of his phenomenal success. And it is 
essential to impress upon the parents that unless they themselves are 
endoAved with an ample supply of patience, tact and perseverance, 
to keep on teaching their child the same thing for days, Aveeks and 
months, this work should be intrusted to some one avIio possesses these 
qualities, or no great achieA^ements need be expected. 

Finally, in training the Aveak-minded it is Avell to remember that 
the unfortunate baby is not to be blamed for his failure promptly to 
apprehend and to copy the apparently simplest rudiments of thought 
and action. He is heartily to be pitied rather than disdained; and as 
the great majority of aments are providentially blessed with a con- 



746 DISEASES OF CHILDREN 

tent and joyful disposition, we might as well refrain from shattering 
their peace of mind by undue harshness or rough handling. 

Medicinal Treatment 

When discussing cretinism, attention has been directed to the mar- 
velous physical and mental transformation occurring on the adminis- 
tration of thyroid extract in amentia due to thyroid insufficiency. 
Wherever the cause of amentia was uncertain, I made it a rule, to 
give the child the benefit of a few weeks' thyroid treatment in order 
to determine, whether or not the thyroid was at fault. Moreover, for 
the last two or three years I believe to have found it of advantage to 
supplement the thyroid medication by the extracts of parathyroid, 
thymus, and pineal and pituitary glands, in accordance with the es- 
tablished fact that whenever the thyroid is affected, the functions of 
the other glands are also more or less impaired. In one case, particu- 
larly, the effect of the combined glandular medication was singularly 
striking. It concerned a six-year-old boy who for three years had 
been treated with thyroid extract by several eminent clinicians. 
When I first saw him he measured 35 inches in height and weighed 
41 pounds. His voice was husky, and he could pronounce but a few 
words in a draggy, staccato sort of fashion. His face and lips were 
edematous, and his tongue protruded slightly. When led by the 
hand he was able leisurely and awkwardly to move along, but if left 
alone he was barely able to take a few steps without stumbling. I 
put him on the aforementioned glandular extract compound, and he 
gained l 1 ^ inches in height, 3 pounds in weight, and a great deal in 
intelligence. He became so active that the mother experienced con- 
siderable difficulty to "restrain him from following the boys in the 
gutter." As, until he came under my observation, he had regularly 
been receiving from 2 to 5 grains of thyroid extract daily without 
appreciable benefit, I could not help but believe that the marked im- 
provement in his condition was due solely to the addition of the para- 
thyroid, thymus, pineal and pituitary extracts. The mode of ad- 
ministration of the glandular extracts varies somewhat with the age 
of the child and the degree and duration of the affection. In con- 
genital cretinism I order 1 grain of thyroid powder twice a day, to a 
bottle-fed baby, and only half the quantity to a breast-fed infant, 
having observed that the latter develops the manifestations of cretin- 
ism more slowly than the former, owing probably to the fact that the 
breast baby in the first few months of life receives some thyroid 
through the mother's milk. If the case fails to show improvement in 
about four weeks, I begin to alternate with *4 grain each of 



AMENTIA 747 

parathyroid, thymus, pineal and pituitary extract. This represents 
the usual dosage for an infant up to one year of age. Older children 
should receive 14 grain of the thyroid powder and % grain of each 
of the other glandular substances for every additional year of their 
respective ages up to five years. The dosage in tablet-form is about 
twice as large as that of the powder. After considerable improve- 
ment has taken place in the child's general development, the dose of 
the thyroid or the compound should gradually be reduced to once a day, 
once every alternate day, and once every third day. Where organo- 
therapy gives rise to cardiac palpitation, undue restlessness, or gas- 
tric irritability, the treatment should temporarily be suspended until 
the toxic symptoms have disappeared, when the medication should 
be resumed in smaller quantities, and gradually increased. 

There are several other medicinal preparations which have to be 
resorted to in the management of the different forms of amentia. Re- 
gardless of cause, it is often judicious to place an anient on a thorough 
antisyphilitic treatment, more especially, of course, when the Wasser- 
mann reaction is positive or there are reasons to suspect syphilis 
either from the history of the case or appearance of the patient. 
Opinions are still at variance as regards the advisability of employ- 
ing neosalvarsan in the treatment of syphilitic amentia in children, 
and I am inclined to give preference to the mixed iodide and mercury 
treatment, unless there be special need for hasty action, e. g., syphil- 
itic hydrocephalus with marked intracranial pressure. If neosal- 
varsan is indicated it should be administered either intravenously or 
intramuscularly. The usual dose and mode of administration is fully 
given when discussing the treatment of syphilis (see p. 494). The 
effect of the neosalvarsan should be controlled by the Wassermann 
reaction, a second dose being administered after two weeks if necessity 
arises. 

The iodides are indicated even in the absence of a syphilitic taint, 
acting as they do as powerful alteratives and eliminants of divers sys- 
temic poisons. One grain of the sodium iodide, twice daily, for every 
year of the child's age, is ample for ordinary purposes. The syrup 
iodide of iron in 10 to 20 drop doses may be alternated with the sodium 
iodide, or some of the newer iodide preparations may be used instead. 
To obtain results the iodide should be continued for several months, 
with occasional intermissions of short duration, in order to avoid gastric 
irritation. It is often found very beneficial to combine the syrup iodide 
of iron with cod liver oil and the syrup of lime hypophosphites, more 
especially where rachitis -complicates the amentia. General tonics and 
appetizers are almost always indicated, for we hardly could make proper 



748 DISEASES OF CHILDREN 

use of our incentive method of training, when the incentive, hunger, is 
lacking. Small doses of the tincture of mix vomica and cinchona com- 
pound, in orange syrup, before meals, and dilute hydrochloric acid and 
essence of pepsin after meals, act exceedingly well both as tonics and 
digestants and should be prescribed as necessity arises. In paralysis or 
general muscular debility it is often advisable to administer strychnine 
by mouth or even hypodermically. One-three-hundredth of a grain 
for every year of the child's age up to five years will ordinarily suffice 
in cases of moderate severity. The dose may be repeated twice or three 
times a day. Sometimes sedatives are indicated, and I have found that 
small, frequently repeated doses of codeine, dionin or heroin, act very 
much more promptly in relieving attacks of twitching, extreme restless- 
ness and insomnia, than the bromides or other hypnotics. Of course, 
in epilepsy, the bromides or luminal are indispensable, and instead of, as 
is usually advised, giving small, gradually increased quantities of bro- 
mide, I have found it very much more profitable to start with large doses, 
and to reduce them, after the periodic attacks have been arrested. Thus, 
for every year of the child's age I'give 1 grain each of potassium, sodium 
and strontium bromide, three times a day, and continue the same until 
I have succeeded in arresting the usual fit for several months. Then the 
dosage may slowly be reduced if it is found that the child is too drowsy 
or signs of bromism make their appearance. I prefer to combine the 
bromides with small doses of Fowler's solution and the mixture of rhu- 
barb and soda, the arsenic seemingh^ preventing bromism white at the 
same time acting as a nerve tonic, and the rhubarb and soda serving to 
subdue the undue gastric irritation. In habitual constipation which is 
the rule in mentally deficient babies, V2 grain of phenolphthalein or 10 
drops of aromatic fluid extract of cascara sagrada, for every year of the 
child's age, or liquid petrolatum in teaspoonful doses will be found 
efficient, particularly if the movement be started with a small injection 
of warm soap water or glycerine suppository. In very young infants 
milk of magnesia (1 or 2 teaspoonfuls, best mixed with the entire 24 
hours' quantity of milk) usually answers the purpose. Special atten- 
tion should be paid to the nasopharynx. "Where adenoids exist and 
greatly interfere with respiration, they should be promptly removed, 
otherwise they can be kept from doing much harm by keeping the naso- 
pharynx clean with Dobell's solution and adrenalin (1:1000), equal 
parts, and the instillation into each nostril of a few drops of a 10 per 
cent solution of argyrol, solargentum, or the like, twice a week, until the 
inflammation and hypertrophy of the adenoid tissue has considerably 
subsided. Intercurrent diseases, of course, must be treated according 
to indications in the same manner in aments as in normal children, ex- 



AMENTIA 749 

cept that greater attention must be paid to the prevention of passive, 
hypostatic pneumonia, and even to trifling ailments which ordinarily 
are entirely free from complications in normally developed children. 

Surgical Treatment 

Surgery as an aid in the cure of idiocy and the allied mental defi- 
ciencies has been resorted to especially during the last two decades. 
The results obtained, however, are far from being satisfactory, except 
in cases of paralytic amentia due to cerebral compression, where early 
decompression has not rarely brought about complete regeneration of 
the brain tissues involved and restitutio ad integrum. Harvey Cushing 
has performed quite a number of craniectomies on the newborn to re- 
lieve cerebral compression resulting from intracranial hemorrhage 
during birth (which, as previously mentioned, forms the cause of 
amentia in about 30 per cent of the cases on record), and is of the 
opinion that with proper regard of hemostasis and careful avoidance 
of undue exposure, the newborn will stand a cranial operation well, 
its life will often be saved, and in many instances develop normally. 
Roswell Park maintained that where a reasonable integrity of brain 
structure can be assumed, there was no reason why craniectomy or de- 
compression should not be given an opportunity in imbecility and 
psychic disturbances, in order to relieve pressure and permit more 
normal development. And William Sharpe and H. F. Farrell claim* 
very good results from cranial decompression in cases of spastic pa- 
ralysis (with mental deficiency) of hemiplegic, paraplegic, and di- 
plegic type with a definite history of difficult labor with or without 
the use of instruments, in which on ophthalmoscopic examination signs 
of intracranial pressure are shown in the dilated retinal veins, and a 
blurring and haziness of the optic discs, especially of their nasal halves. 
In these cases they perform a large, right subtemporal decompression, 
and if the intracranial pressure remains high, they perform a left sub- 
temporal decompression the following month. The after-treatment 
which is of very great importance, consists in the correction of de- 
formities by tendon lengthening and stretching of the contracted 
muscles : the maintenance of the corrected positions by the employment 
of especially adapted and properly fitting braces, and skilled massage 
in conjunction with short applications of galvanism and faradism. A 
careful, systematic course of muscle training is carried out daily. 
Sharpe and Farrell claim marked improvement not only in the spas- 
ticity but in the mental condition of the patients as well, so much so 



( In several eases under observation the results proved negative. 



750 DISEASES OF CHILDREN 

that they are able "to receive the cooperation of the patient in the 
carrying out of the after-treatment." Of course, the earlier the de- 
compression is performed the greater the opportunity and facility for 
the compressed brain structures to adjust themselves in their normal 
relations and to regain their normal functions. 

As has already been stated the results from operative interference 
in the other forms of amentia are, to say the least, but temporary. 
Lannelogue's craniectomy for the relief of microcephalus, which at 
first was hailed as a great success, soon proved a total failure and has 
rightly been abandoned even by its most enthusiastic exponents. Sev- 
eral operations have recently been proposed for the cure of hydro- 
cephalus, but it is too early to arrive at correct conclusions regarding 
the improvement in the child's mentality and its permanency. Of these 
operations I may mention G. Anton's efforts to relieve intracranial 
pressure by puncture of the corpus callosum, and Irving S. Haynes' 
method of treating hydrocephalus by cisterna-sinus drainage. 

In recommending operative interference for the relief of congenital 
or acquired physical defects complicating amentia and for the eventual 
restoration to normal mentality, considerable conservatism, of course, 
should be exercised in the proper selection of the cases. But, when- 
ever in our judgment the case in question is entirely hopeless if left 
alone, and there is the remotest chance, through surgical interference 
to relieve the idiot of his lifelong misery, we should not at all hesitate 
to recommend surgical treatment, notwithstanding the accompanying 
appalling mortality. However, before resorting to surgical interven- 
tion, the mental defective should for a reasonable time be given the 
benefit of some of the other therapeutic measures here suggested. 

Prognosis 

Do what you will, even under most scrupulous application of all of 
the aforementioned preventive and curative measures, amentia, either 
of prenatal, natal, or postnatal origin, will persist and exist as long as 
man will inhabit this world. Fortunately the majority of cases of 
genuine congenital idiots are usually short lived. This is true espe- 
cially of the congenital hydrocephalic, paralytic (associated with poren- 
cephaly and cerebral sclerosis), Mongolian with congenital heart dis- 
ease, and the amaurotic. The great majority of them succumb during 
early infancy or childhood, either to general debility or to intercurrent 
diseases, more particularly pneumonia and tuberculosis. The pneu- 
monia is usually of the hypostatic variety that readily supervenes 
after trifling ailments which in any way tend to depress the vitality 
of these weaklings. The prevalence of tuberculosis among them can 



AMENTIA 751 

often be traced to an hereditary disposition, superinduced by the ever 
present nasopharyngitis and adenoids, or to direct infection of the 
alimentary or respiratory tract as a result of the extremely unhygienic 
habits of the majority of low grade aments. As is well known, idiots 
delight in rolling in filth and chewing on anything and everything 
picked from dirty floors and streets, and it is quite reasonable to sup- 
pose that these things harbor a multitude of pathogenic microorgan- 
isms, the tubercle bacillus among them. On rare occasions we meet 
with aments of very robust constitution, who are not susceptible to the 
ordinary children's diseases, and often, almost for spite, surmount 
violent attacks of exanthemata, gastroenteritis and the like, even if 
left alone without proper hygienic care, suitable feeding or medication. 
This is often true of the microcephalic idiot with the miniature brain 
and head (see p. 707), and the postnatal cretin. 

The mortality in feeble-mindedness of postnatal origin, more espe- 
cially in children who receive good care and treatment, as a rule, is 
not much higher than in normal children, provided they remain free 
from convulsive seizures and are able to be around and about. As 
regards the future mental progress of aments, each case must be 
judged individually. As a rule, however, mentally deficient children 
who at about three years of age are able to make more or less free 
use of their extremities, in the course of time are amenable to proper 
training. Some of them as they grow older can be made useful by 
teaching them light outdoor occupations, such as gardening, or to 
assist in farming, others by learning to help along in different trades, 
6. g., basket making, carpet laying, carpentry, and others again by do- 
ing errands, etc. Under these circumstances, more particularly, since 
errors in the diagnosis of the exact type of amentia dealt with are not 
at all uncommon even with the most experienced observers, it is hardly 
just or expedient to declare a case of feeble-mindedness unimprovable 
without giving it a fair test by way of physical and mental training, 
or, possibly medical or surgical treatment, whenever there is reason 
to believe that these therapeutic measures might prove of some bene- 
fit to the child, or at least will do no harm. 

AMENTIA IN OLDER CHILDREN 

Epileptic Idiocy 

In discussing epilepsy (see p. 651) attention has been called to the 
severe mental impairment following and often accompanying recur- 
rent epileptic attacks. In a great many cases the fits and the idiocy 
are based upon the same pathologic condition of the brain. G-. H. 



t'O J, DISEASES OF CHILDREN 

Savage remarks that the epileptic idiot is the drollest inhabitant of 
the idiot asylum. He is often wild, untractable, and irritable, many of 
the symptoms resembling those of ordinary insanity. The management 
of epileptic idiocy is the same as in epilepsy (q. v.). As the condition 
is practically hopeless, there need be less conservatism in advocating 
operative interference. 

Imbecility 

Imbecility is closely related to idiocy, and is based upon some in- 
herent mental privation which no amount of education can entirely 
overcome. It may be the result either of congenital or acquired struc- 
tural cerebral derangement consecutive to febrile affections or endocrine 




Fig. 226. — Feeble-mindedness in a boy eight years old following an attack of 
encephalitis; lie is suffering also from slight left hemiplegia. His mental age is 
that of a boy four years old. 

disturbances, The condition is usually not detected until the child goes 
to school, when it is found that as compared with the normal pupil 
lie is backward in understanding and reasoning, though he may be 
singularly developed in special directions, e. g., memory, mechanical 
aptitude. Further observation reveals also that the imbecile is ex- 



AMENTIA 753 

ceedingly emotional easily irritated and appeased with difficulty, shows 
an irresistible passion to lie, steal and play truant, and that long before 
maturity his sexual inclinations are in the highest state of depravity. 
His moral decrepitude increases from year to year, and may range 
from theft, arson and rape to homicide and suicide. 

Imbeciles should be placed under the control of experienced peda- 
gogues, preferably in some lonely country place. 

Bixet-Simox Test of Mental Development* 

It is now possible by means of this scale to determine fairly well 
the mental age of children. There will be much less indefiniteness 
regarding the terms used in designating the types of feeble-mindedness. 

Thus, the term " idiot," which is technically restricted to those who 
cannot talk, corresponds to the mental age of one and two years. 

The term "imbecile," which includes persons who understand 
spoken language and talk with varying degrees of fluency, corre- 
sponds to the mental age of three, four, five, six, and seven years. 

The "moron" is one who. in addition to using spoken language, is 
capable of learning to read and write, and he corresponds to the 
mental age of eight, nine, ten. and eleven years. 

The feeble-minded are persons who include all three groups and 
hence correspond to the mental age of from one to twelve years. A 
person having the mental age of twelve may be retarded, but is not 
feeble-minded, and technically the retarded would be persons who 
have the mental age of twelve to fifteen years and who do not get 
beyond it. 

Mental Age 5 Years! 

Place two boxes weighing 14 and 1 2 ounce respectively on the table 
before the child, leaving a space of 2 inches between them, and say, 
"You see these two boxes? Tell me which is the heavier. Repeat using 
boxes weighing U and % of an ounce, and repeat again, using first pair. 

Place an oblong card on the table before the child and place also, 
nearer to the child, two triangular cards formed by cutting another 
card like the first one in two, along a diagonal. Place these two tri- 
angular cards in such position that their hypothenuses form a right angle 
one with the other, then say to the child, "Put these two pieces to- 
gether so that they will form one card like this," (indicating the oblong 
card). If the child turns over one triangular piece without noticing it, 
it is permissible to begin again. 



*The tests are modified to correspond to the more advanced intelligence of modem children. 
fThe mental tests for children under five years are given on p. 705. 



754 DISEASES OF CHILDREN 

Ask child — 

"Is it morning- now?" "Is it afternoon?" "What is a fork?" 
"What is a table?" "What is a chair?" "What is a horse?" "What 
is a mama ? ' ' 

If some use of three of the objects is mentioned the response is con- 
sidered correct. 

Draw a diamond figure with ink and ask the child to copy it, giving 
him pen and ink for the purpose. 

Place 13 pennies in a row on the table before the child and say, 
"Count these pennies for me, pointing to each one as you count it." 

Mental Age 6 Years 

"Say after me, 4, 7, 3, 9, 5, and repeat it yourself." 

Draw a square 3 to 4 cm. in diameter with ink and ask the child to 
copy it, giving him pen and ink to do so. 

Place one two cent and one one cent stamp on the table before the 
child, and then ask him to count how much they would all cost. 

Have four pieces of colored paper, red, blue, yellow, and green. 
Point to each, asking, "What is this color?" 

How many fingers have you on your right hand? 

Mental Age 7 Years 

(a) "Do you know what paper is?" "Do you know what cardboard 
is?" "Are they alike?" "In what way are they not alike?" 

(b) "Have you ever seen a fly?" "Have you ever seen a butterfly?" 
"Are they alike?" "In what way are they not alike?" 

(c) "Do you know wood when you see it?" "Do you know glass 
when you see it?" "Are they alike?" "In what way are they not 
alike?" Two satisfactory answers required. 

"I want you to count backward from 20 to 0. Like this — 20 — 19 — ■ 
18." This must be accomplished in 30 seconds. One error allowed. 

"What day is to-day??" "What date is it?" 

"Listen well and repeat what I say: 3-8-5-7-1; 9-2-7-3-6; and 5-1-8- 
3-9." One group given at a time. 

Mental Age 8 Years 

Show the child successively a penny, a dime, a dollar, a quarter, a 
nickel, a half dollar, a two dollar bill, a ten dollar bill, a five dollar bill. 
Ask, "What is this?" with each. 

In a pile before the child place the following coins : Ten pennies, two 
nickels, two dimes, one quarter, one half dollar. Then propose a game 



AMENTIA 755 

of storekeeping, the child to keep the store and use the pile of money 
to make change, the experimenter to be the customer. Add some 
articles for sale. Then buy something for four cents. Give the child 
a quarter and require the change. 

"Name the months of the year in order." One error allowed, time 15 
seconds. 

"If you were going away and missed your train, what would you 
do." 

"If one of the boys should hit you without meaning to, what would 
you do about it?" 

"If you broke something belonging to some one else, what would 
you do about it?" Two good responses required. 

Mental Age 9 Years 

Place on the table before the child five boxes weighing 3, 6, 9, 12 and 
15 grams respectively. Say to him, "These little boxes all weigh dif- 
ferent amounts. Some are heavier and some lighter. I want you to 
place the heaviest here and by its side the one which is a little less 
heavy and then the one a little less heavy and the one still a little less 
heavy, and finally here the lightest." Three trials made, the ooxes mixed 
after each. Two successes in three are required. 

"I am going to show you two drawings! and after you have looked at 
them I shall take them away and ask you to draw them from memory. 
You must look at them closely because you will have them for ten 
seconds and this is a very short time." 

Full credit is given if the whole of one drawing and half of the other 
is reproduced exactly. 

"I am going to read you some sentences; in each one of them there 
is something foolish or absurd. You listen carefully and tell me each 
time what it is that is foolish. ' ' 

(a) "An unlucky bicycle rider fell on his head and was instantly 
killed ; they took him to the hospital and fear that he cannot get well. ' ' 
After a pause — "What is foolish in that?" 

(o) "I have three brothers, Paul, Ernest, and myself" — "What is 
foolish in that?" 

(c) "The body of a young girl cut into 18 pieces was found yester- 
day. People think that she killed herself. ' ' — ' ' What is foolish in that ? ' ' 

(d) "There was a railroad accident yesterday, but not a serious one, 
only 48 persons were killed." — "What is foolish in that?" 

(e) "A man said: 'If I should ever grow desperate and kill myself 



f Simple figures, e. g., table, chair. 



756 DISEASES OF CHILDREN 

I should Dot use Friday For the purpose because Frdiay is an unlucky 
day and might bring me unhappiness. ' " — "What is foolish in that?" 
Correct solution of three of the five statements required. 

Mental Age 10 Years 

(a) "If you were delayed on your way to school, what would you do 
about it?" 

(b) "Before taking part in something very important what would 
you do?" 

(c) "Why do we more easily pardon a bad act done in anger than 
a bad one done without anger?" 

(el) "If some one should ask your opinion of one whom you did not 
know very well, what would you say?" 

(e) "Why should we judge a person by his acts rather than by his 
words?" 

Two errors allowed. 

Write the words Paris, fortune, stream. Show them to the child, 
reading them to him several times. Then give him pen and ink and 
tell him to write a sentence containing all three of these words. 

Mental Age 11 Years 

"I want you to say just as many words as you can in three minutes. 
Some boys say as many as two hundred. Now you must try and see 
how many you can think of." 

Sixty words the minim ion accepted. 

"What does charity mean?" "What does justice mean?" "What 
does kindness mean?" Two correct answers required. 

"Find the sentences which these words make. Fix the words in their 
proper order." 

( a ) At-country-we-f or-started-hour-an-the-early . 

( 1) ) Teacher-I-to-my-exercise-asked-my-correct. 

(c) Defends-a-his-dog-master-gocd-bravely. 

The intelligence of a child is judged not only by the answer he 
gives, but also by the way he gives it, and the manner in which he goes 
about it. Some children, although very bright, may be very careless 
in listening to the question and give an answer which, although not 
correct, is nevertheless very sensible. Moreover it is well to bear in 
mind the fact that some children may be somewhat deficient in certain di- 
rections (e. g., drawing) and yet perfectly normal as regards their 
general intelligence. 



AMENTIA 



757 



Mental Affections in Older Children 

Exempting hysteria, (q. v.) epileptic idiocy and imbecility, mental 
affections in children under twelve years of age are very rarely met in 
daily practice, hence no effort will here be made to dwell upon the sub- 
ject very extensively. Attention, however, will be directed to the more 
common, though very rare, mental diseases occurring in children ap- 
proaching puberty and adolescence. 

Dementia 

Acute dementia is rare in children under twelve years of age. 
It is apt to follow severe infectious diseases, such as typhoid fever, 
influenza, or scarlatina, or sudden shock and mental and physical 
overexertion. It is manifested by gradual weakening of the mind, 




Fig. 227. — Dementia precox in a girl thirteen years old. Xote also cystic degenera- 
tion of the thyroid gland. 

characterized by loss of memory, lack of power of attention, inter- 
est, and curiosity, and tendency to stupor. After weeks or months of 
rest, ample nutrition and tonic treatment there is usually a progress- 
ive return of the intellect and gradual recovery. More rarely it 
terminates in permanent weakmindedness. 

Dementia Precox Katatonia Hebephrenia 

This mental affection is usually encountered in children over ten years 
of age, and especially in girls at the period of puberty. It usually begins 



758 DISEASES OF CHILDREN 

with a prodromic stage of depression and apathy during which the child 
loses interest in her school work, and complains of divers imaginary ail- 
ments. Loss of memory, especially for recent events, and gradual, pro- 
gressive, intellectual enfeeblement form characteristic symptoms. The 
stage of apathy is soon followed by one of anxiety and hallucinations or 
outbreaks of emotional excitement, silly and hilarious in nature. As the 
disease advances the condition is often complicated by manifestations of 
mania with a marked tendency to destructiveness and violence, oc- 
casionally also by attacks of stupor, catalepsy, affection of speech, 
refusal of food, convulsive movements, etc. 

In favorable cases the mental disturbance gradually subsides within 
a few weeks or months, often leaving behind symptoms of imbecility. 
In unfavorable cases the disease passes into a state of total idiocy. 
Little if anything can be done to influence the course of the affec- 
tion. 

Illustrative Case (Fig. 277). — When I first saw her she was thirteen 
years old. She was five feet six inches in height, and slender in build, 
weighing one hundred and twelve pounds. Her general health was good 
and her heart 's action slow and regular. Her menstruation had not set in 
and her mammary glands were not developed. Her head was large and 
covered by a fair supply of normal hair. Her eyes were large, but not 
bulging, and her facial features seemed normal, when she was not laugh- 
ing — which latter was rarely the case, especially when spoken to. When 
addressed she would invariably grin (that peculiar idiotic grin) or laugh 
aloud for several minutes at a time, open her mouth very wide and show a 
set of ugly, big, blackish brown, partially decayed, crooked teeth. 
Examination of the neck revealed a large, elastic, cyst-like swelling, 
spreading out as a broad goitrous mass, especially to the right. Ac- 
cording to the mother the tumor developed gradually within about two 
years previous to my examination. The family history was apparently 
negative. The parents were hard-working, healthy people, and their 
two other children were well. The patient's mental condition was 
supposed to have been quite good up to ten years of age. At about 
that time it was noticed that she lost interest in her school work, be- 
came slovenly and forgetful and very " nervous." As weeks and 
months passed by her feeble-mindedness grew more and more pro- 
nounced, so that on coming under my observation I found her essen- 
tially idiotic. As already stated, when addressed she would grin 
and laugh; when questioned about something, she would turn to her 
mother and partly repeat what the mother had to say ; she was unable 



AMENTIA 759 

to add together, for example, two and two, and had no idea of where 
she lived. She was extremely restless and disturbed by the slight- 
est commotion, and like a frightened baby was closely clinging to her 
mother's side. I put her on slowly increasing doses of thyroid ex- 
tract, but it had no beneficial effect upon her feeble mentality — her 
condition remained stationary for several months. I lost track of her 
for about six months thereafter, when one day I read in the daily 
press that on being sent to a grocery store across the street she had 
lost her way back home and was picked up by a policeman the fol- 
lowing day, exhausted from hunger, thirst, and fatigue, wading knee- 
deep in the swamps of Westchester and unable to give any information 
as to her name or place of residence. After a few similar escapades 
she was finally committed to an insane asylum. 

Dementia Paralytica 

Dementia paralytica, which is very uncommon in children and 
usually based upon hereditary syphilis, presents identical symptoms 
as in adults. Thus, tremor, slurring speech, pupillary inequality, 
ataxia, trophic changes, and paresis ; gradual loss of intellect with 
development of unsystematized ideas of self-importance. The course of 
this form of dementia is chronic (several years) and invariably ends 
fatally. Slight improvement may occasionally be observed from 
cautious use of mercury and the iodids. 

Melancholia 

Mental depression is not rarely observed in children from ten to 
fifteen years of age and sometimes in younger ones. The child re- 
fuses to play, laments, and cries, broods over imaginary wrong acts 
and occasionally falls into paroxysms of rage. Melancholia not rarely 
leads to attempts of self-destruction. 

The prognosis of this affection is fairly favorable (after weeks or 
months), some cases, however, may proceed to mania or even de- 
mentia. 

Rest and good food are essential in the treatment. 

Mania 

In contrast to melancholia, mania is characterized by accelera- 
tion of every physical and mental activity. Thoughts and impulses 
follow one another with unusual rapidity. The patient talks, 
rages, screams and tries to destroy everything in sight. She also 
suffers from hallucinations and delusions of greatness. While mania 



760 DISEASES OF CHILDREN 

often ends in recovery after from six to twelve months, it also shows 
a great tendency to recurrence or to alternate with attacks of melan- 
cholia — circular insanity — in which event the prognosis is very bad. 

The treatment, in addition to rest and proper nourishment is symp- 
tomatic — calming of the excitement by means of hyoscine hydro- 
bromate, and other hypnotics. Luminal, gr. V/o twice a day will be found 
exceedingly useful as a general nerve sedative. 

Mental affections in older children are best treated in sanitaria, 
away from friends and relatives. As the majority of them refuse to 
eat, and as ample nutrition is essential to recovery, we are often forced 
to feed these patients by a stomach tube introduced through the nose. 
Of course, for this purpose only liquid food is available, such as rich 
milk, fermented milk, broths and fruit juices. Medicines also may be 
given in this manner. 



CHAPTER XIV 
DISEASES OF THE SKIN 

Skin affections of children like those of adults may be classified 
into systemic and local. To the former class belong chiefly the large 
group of exanthemata ; the rashes arising as a result of faulty metab- 
olism and autointoxication, including the different forms of purpura, 
erythema and drug eruptions ; the syphilides and tuberculous lesions 
and the obscure dermatoneuroses. The local skin diseases embrace 
the local parasitic affections, the lesions following mechanic, trau- 
matic, thermic and chemic irritations. 

Since the greater number of systemic morbid skin manifestations 
have received due consideration in connection with the underlying 
diseases, we shall here limit our discussion to the skin eruptions which 
yield principally to local treatment. 

Eczema 

Eczema in children is usually observed in subacute or chronic form. 
It ordinarily begins with localized, more rarely diffuse, redness of 
the skin, slight edema, burning and itching. The condition is soon 



5 * '*$ * 




1 


-rf ' ■# 











Fig. 22S. — Seborrheic eczema of head and face. 



aggravated by the appearance of papules, vesicles, and pustules, and, 

if not promptly responding to treatment, by scabs, scales and fissures. 

Eczema may remain localized, especially on the face and head, or 

become generalized. Eczema of the face and head is usually seen in 

761 



762 DISEASES OF CHILDREN 

young infants, and is very refractory to treatment. In its typical 
form, the eruption of eczema faciei is generally spoken of as "crusta 
lactea," and consists of more or less coherent scabs of greenish or 
blackish-brown color, here and there interrupted by areas of red, 
moist ("weeping surface") and excoriated skin. From the face the 
eruption usually extends to the forehead, ears and head (eczema or 
seborrhea capitis). After prolonged duration the hair loses its lus- 
ter, becomes thin and short, and the adjacent glands are painful and 
swollen, and often the seat of a pustular eruption as a result of 
scratching and secondary infection. 

The course of eczema is very tedious. It may last weeks, months, 
or years. Improvement often alternates with aggravation of the con- 
dition. This is true especially of eczema accompanying constitutional 
derangement, e. g., gastrointestinal intoxication (see "Exudative Dia- 
theses." p. 521). The duration of the disease is often prolonged by 
infection of the diseased as well as healthy areas with divers parasites 
during the act of scratching. 

Treatment. — The success in the management of eczema, depends 
greatly upon the ease with which the underlying causes can be pre- 
vented or removed. The infantile skin being very delicate and vul- 
nerable, it is essential to a\^oid its undue exposure to mechanical 
(scratching; woolen, rough underwear, etc.), thermal (excessive heat 
or cold, also direct action of the sun, etc.), and chemical (rubefacients, 
irritating soaps, urine, acrid discharges, etc.) irritation. Tne diet 
should be bland and regulated as to the time of feeding and its quan- 
tity. In protracted cases the Allergy test (q. v.) is often help- 
ful in eliminating the toxic etiologic agent of the disease. Where 
microscopic and chemic examinations of the stools show inabil- 
ity to assimilate fats or carbohydrate, these must be either re- 
stricted or entirely eliminated. Sometimes good results are obtained 
from removal of sugar from the dietary. Plenty of water is often 
helpful. Constipation should be promptly remedied. Cleanliness of 
the skin and everything coming in contact with it should be insured. 

The active treatment of eczema should be regulated in accord with 
the stage of the disease. While the skin is highly inflamed, all sorts 
of irritation should be interdicted. Tub bathing of the entire body 
should be discontinued for a time, first, because of the tendency of 
water to irritate the denuded skin, and, secondly, in view of the pos- 
sibility — particularly in eczema due to external parasitic infection — of 
conveying the disease from one portion of the skin to the other. The 
healthy parts of the body, however, should be kept scrupulously clean 
by frequent sponging followed by careful drying. 



DISEASES OF THE SKIN 



763 



The following soothing and protective ointment employed with 
great success at the New York Post-Graduate Hospital, will be found 
invaluable in the great majority of acute or subacute cases: 

I* Zinci oxidi, 

Pulveris cretae aa 3iv I 16 

Mix, and add with constant stirring: 

Olei lini (hot), 

Liq. plumbi subaeet. dil aa 3ij I 8 



The ointment is applied once or twice a day thickly over the af- 
fected areas and covered by sterile gauze held in place by means of a 
bandage. Scratching of the skin should be prevented by mechanical 
means, such as celluloid armlets, and the like. Excoriated surfaces 
often heal promptly after painting with a 2 per cent solution of 
nitrate of silver. In subacute cases Dunn recommends the following 
ointment : 



Acidi Carbolici 


gr. x 


0.60 


Hydrargyri Chloridi Mitis 


gr. xv 


1.00 


Amyli 






Zinci Oxidi 


aa 3i 


4.00 


Vaselini 


S 


30.00 


. Ft. Ung. 







After the inflammation subsides and scales and crusts firmly adhere 
to the skin, the soothing ointments are gradually replaced by those of 
a stimulating nature. The crusts are softened with carbolized oil 
(1 to 100), and gently removed. The hairy portions of the body are 
carefully shaved and cleansed with carbolized oil. After giving the 
affected skin a few hours rest we apply one of the following prepara- 
tions : 



3 



Acidi salicylici, 








Bismuthi subgal. 




aa gr. xx 


1.3 


Thymolis 




gr. v 


0.3 


Pulveris amyli 




3iij 


12 


Ung. hydrargyri 


ammoniati 


3ij 


8 


Ung. zinci oxidi 




q.s. ad Bij 


60 


Kesorcini 




gr. xx 


1.3 


Acidi carbolici 




gr. x 


0.65 


Olei cadini 




m xx 


1.3 


Sulphuris precipitatis 


3ij 


8 


Ung. petrolati 




q.s. ad gij 


60 



High intestinal irrigation once a day with a quart or two of plain 
water or with the addition of a 2 per cent of bicarbonate of soda is 



764 DISEASES OF CHILDREN 

useful in all cases. In gastric hyperacidity carbonate of magnesium 
(gr. xxx, once a day) acts well. Obese children suffering from ob- 
stinate eczema with dryness of the skin often do well on minute doses 
of thyroid extract. Finally, it is worth remembering that protracted 
eczema is occasionally a manifestation of hereditary syphilis, and re- 
sponds promptly to the exhibition of mercury and the iodides. 

Urticaria 

(Hives, Nettle Rash) 

Urticaria is characterized by a multiform eruption of whitish, pink- 
ish, or reddish color upon different portions of the body, which is 
sudden in appearance and disappearance, and shows a tendency to 
repeated recurrences. The eruption may consist of circular or spiral 
elevations ("wheals"), papules, vesicles, or hemorrhagic spots, and 
is generally associated with intense itching and stinging. It is fre- 
quently preceded and accompanied by gastric and nervous disturb- 
ances and rise of temperature. 

Recurrent urticaria is prone to leave behind marked pigmentation 
of the skin or to terminate in prurigo, a very chronic skin affection 
manifested by dryness, hypertrophy and pigmentation of the skin and 
inflammation of the neighboring glands. 

Treatment. — Since in the majority of instances, urticaria in chil- 
dren is the result of faulty feeding, especially of eating candies and 
cakes of poor quality, fish, fresh berries, and the like, it is essential 
to regulate the diet* (in some cases a milk diet is efficient, in others 
again elimination of milk may prove successful), and to clear the 
gastrointestinal tract of the obnoxious material. The latter is best 
accomplished by small doses of calomel, magnesium carbonate and 
sodium bicarbonate and a high enema. To relieve itching we may 
resort to warm baths with bicarbonate of soda (!/2 to 1 pound), 
sponging of the body with vinegar followed by glycerine, or to the 
following preparations: 



3 


Thymolis gr. v to x 0.3 to 0.65 




Ung. aqua? roscc Sj | 30 


M. S.- 


-P. r. n. 


r> 


Aquse ammonise 3ss 


2 




Aquae liamameliclis Siij 


90 


M. S.- 


-Not to be used over abraded portions of the s 


kin. 



*See '"Food Idiosyncrasy," p. 87. 



DISEASES OF THE SKIN 765 



B; Acidi carbolic i 








3ss 


2.00 


Zinci oxidi 








§ss 


15.00 


Glycerini 








3ii 


8.00 


Aq. calcis 








Sviii 


240.00 


M. 










S. — Apply several times 


a day 


and 


allow 


to dr 


y on skin 



Intertrigo 

(Chafing) 

This affection occurs with predilection in localities where opposed 
body surfaces rub against each other, and in the "napkin region." 
It is the result of irritation of the skin by acrid secretions or ex- 
cretions (sweat, diarrheal stools, acid urine, purulent discharges, etc.), 
excessive heat or moisture. Intertrigo usually begins with simple 
erythema. At this stage it readily yields, in addition to removal of 
the etiologic factors, to the application of a dusting powder of: 



B; Zinei stearatis 3iv 

Bismutlii subnitratis gr. xv 

Amyli gj 



15 
1 



and the separation of the opposed surfaces by thin layers of absorbent 
cotton or old, clean linen cloths. As the disease advances, the skin 
becomes glossy, moist, sticky, and denuded of the epidermis, and the 
seat of papules, abscesses and ulcerations. In this condition inter- 
trigo is very refractory to treatment, often demanding a complete 
change in the regime of the baby — beginning with its diet and ending 
up with its nurse. The customary daily tub bath should be replaced 
by a sponge bath, taking special care to keep the affected parts of the 
skin perfectly dry. The denuded skin should once daily be painted 
with a 1 or 2 per cent solution of nitrate of silver, and the entire dis- 
eased surface covered with the following ointments : 

B; Acidi carbolici, 

Balsami Peruviani aa m v I 0.3 

Olei lini, 
Adipis lan», 

Ung. zinci oxidi aa 3iv I 15 

M. S. — To be applied several times a day after carefully 
cleansing (with oil) and drying the affected parts. 

B; Thymolis gr. ii I 0.13 

Dermatolis gr. viii 0.5 

Ung. zinci oxidi q. s. % i 30 

M. 

Sig.— P. r. n. 



766 



DISEASES OF CHILDREN 



Psoriasis 

The disease is very exceptionally met in children under five years 
of age, but is not uncommon in older ones. It begins with minute 
white spots, usually upon the extensor surfaces of the elbows and 
knees and upon the scalp, and gradually assumes the shape of disks 
with tawny-red base and silvery-white scales, not rarely giving the 
skin the appearance of being splashed with mortar. The cause of 
psoriasis being obscure (it is probably of parasitic origin, though it 
seems to run in families), the treatment is necessarily symptomatic; 




Fig. 229. — Psoriasis in a girl seven years old. 

and very unsatisfactory as to ultimate cure. Internally we may try 
small doses of arsenic, to be continued for several months, or thyroid 
extract. Externally we resort to alkaline baths, and, after the re- 
moval of the scales, to an ointment composed of chrysarobin or sali- 
cvlic acid and ichthvol. 



I£ Acidi salicyli, 

Eesoreini, 

Iclithyolis 

Ung. sulpliuris 

M. 
S. — To be applied twice a day. 



aa 3ss I 2 
Sij 60 



DISEASES OF THE SKIN" 



767 



Clirysarobini, 






Ichthvolis 


a a 3j 


4 


Ung. petrolati 


Sj 


60 


M. 






S. — To be applied once or twice a day. 







Herpes Zoster 

(Shingles) 

Contrary to what is observed in adults, herpes zoster in chil- 
dren is rarely accompanied by severe neuralgic pain. The eruption 
usually appears suddenly in the form of groups of vesicles along the 




Fig. 230. — Herpes zoster. 

tracts of either the intercostal or pudendal nerves, or the brachial 
plexus. The vesicles remain either isolated or coalesce and form 
large patches covered by yellowish-brown crusts. Different patches 
often exhibit different stages of development or decline. As a rule, 



768 DISEASES OF CHILDREN 

the eruption is unilateral. The correlation of herpes to varicella has 
been spoken of on p. 395. 

The course of the disease is usually completed within two weeks, 
except in cases leading to deep ulceration and sloughing (herpes 
gangrenosum), a very rare condition, usually the result of secondary 
infection. Treatment consists of local application of a dusting powder 
or ointment composed of stearate of zinc with or without 2 per cent 
of bismuth subnitrate or subgallate. Occasionally the nerve pain 
calls for some anodyne, e. g., sodium salicylate and codeine. 

Miliaria; Lichen Strophulus 

(Prickly Heat) 

This very common affection in infants, especially during first denti- 
tion (corresponding with the period of excessive sweating which 
forms a symptom of rachitis) appears suddenly upon the face, trunk, 
and extremities, either as discrete papules or vesicles from a pinhead 
to half a pea in size, or in groups upon a slightly reddened infiltrated 
base. It is produced by all sorts of external or internal irritations 
(heat, rough flannel underwear, overfeeding, etc.), and readily yields 
to attention to these causes, and the administration of mild laxatives. 
The slight itching may be relieved by cool, alkaline or bran baths, and 
sponging of the body with Dobell's solution. Prickly heat occurs also 
in older children during the summer months and is best treated by 
cool sponging and application of mentholated stearate of zinc. 

Ecthyma 

( PSEUDOFURUNCULOSIS ) 

It consists of pea- to bean-sized, flat pustules surrounded by a red 
zone. The lesions are situated chiefly upon the thighs, legs, shoulders 
and back, and are frequently associated with eczema, probably pro- 
duced by infection of the eczematous lesions during the act of scratch- 
ing. More rarely, they are met in the newborn as a result of lack of 
cleanliness (infection with dirty fingers, cloths, etc.). 

Occasionally the pustules enlarge gradually and burst, leaving be- 
hind deep ulcers which heal very slowly with scar formation. These 
are prone to occur in ill-fed, scrofular or otherwise seriously diseased 
children, and may sometimes end fatally as a result of gangrene of 
the skin. 

Simple ecthyma usually responds to hot baths (with boric acid §ii), 
antiseptic ointments, or cautious sponging of the affected parts of the 
body with the following : 



DISEASES OF THE SKIN 



769 



I£ Etheris, 

Tr. saponis viridis 



aa Sj | 3C 



Large pustules should be treated by incision and antiseptic dress- 
ings. (See "Scrofulosis," p. 460.) Each pustule should be covered 
with zinc adhesive plaster to prevent carrying of the pus to other parts 
of the body. 

Impetigo Contagiosa 

The favorite seat of impetigo is the face, hands, and scalp, but the 
other portions of the body are not exempt from the inoculation. 

The eruption begins as small groups of minute vesicopapules which 
soon burst and dry up into yellowish crusts. \Yhen the crust has 
lasted for some time, its surface becomes slightly lamellated and its 
edge detached, the crust then presenting the appearance as if "stuck 




Fig. 231. — Impetigo contagiosa of an unusually severe type. (Courtesy of Dr. L. W. 

Ketron.) 

on" to the healthy skin. The surface beneath the crust is raw and 
suppurating. 

If further autoinoculation of the disease is prevented (by covering 
with gauze and zinc adhesive plaster), impetigo usually heals spon- 
taneously in about ten days. Otherwise, by the development of neiv 
lesions, it may persist for several weeks. 

Treatment. — In view of the highly contagious nature of the dis- 
ease and its tendency to run in epidemic form through schools or 



770 



DISEASES OF CHILDREN 



asylums, it is imperative to isolate all those children who are suffer- 
ing from this disease and to employ active therapeutic measures to 
eradicate it. 

This is readily accomplished by means of local antisepsis. After 
softening the crusts with warm carbolizecl sweet oil (1 per cent), 
and removing them, and thoroughly washing the diseased surface 
with green soap, the spots are touched up with a 2 to 5 per cent solu- 
tion of nitrate of silver, and covered over with sterile gauze and ad- 
hesive plaster. This treatment is repeated for a few days and fol- 
lowed up with a 25 per cent ichthyol in a sulphur ointment. 

Simple impetigo differs from the contagious variety by its lesions 
being pustular from the beginning and by showing no tendency to 
coalesce in large patches and to spread to other portions of the body. 
There is no history of contagion. 

Pediculosis Capitis 

(Head Lice) 

The favorite seat of the head louse is the occipital portion of the 
scalp. In cases where the hair is thick and the parasites are few in 




Fig. 232. — Pediculosis capitis, showing ova on hairs. (Courtesy of Dr. J. E. Lane.) 



DISEASES OF THE SKIN 771 

number and hence not easily seen, their presence can readily be sur- 
mised by the existence of ova (nits), which are firmly attached to the 
shafts of the hair. The lesions produced by pediculi resemble those of 
eczema of the head — pustules, scabs, matting of the hair, intense itch- 
ing", and marked enlargement of the glands of the neck. 

Treatment. — Children affected by pediculosis should be isolated for 
a few days until the disease is cured. The hair should be clipped, the 
scalp thoroughly cleansed with the tincture of green soap and then 
dressed with a cloth dipped in petroleum or the tincture of larkspur 
(delphinium). A few such dressings usually suffice to effect a cure. 
After removal of the pediculi the scalp should be cleared of its re- 
maining eruption by an antiseptic ointment (e. g., unguentum sul- 
phuris). 

Pediculosis Corporis 

(Body Lice) 

Body lice are seldom seen in young children. They give rise to 
red dots, itching and scratch marks. The diagnosis is settled by find- 
ing the parasite in the clothing or on the body of the child. 

Treatment. — The treatment consists in destroying or baking the 
infested garments, scrubbing the child's body with green soap, and 
the application of a zinc and sulphur ointment until the eruption has 
entirely disappeared. 

Pediculosis Pubis 

(Crab Lice) 

This skin affection is of diagnostic interest, principally because of 
the power of the crab louse to infest in addition to the hair of the 
pubis, abdomen, chest and axilla, also the eyebrows and eyelashes, in 
the latter case giving rise to a clinical picture resembling blephar- 
itis. 

The insect succumbs rapidly to the effects of mercury ointment: 

J^ Ung. hydrarg. nitratis 3j 4 

Ung. petrolati 3iij J 2 
M. 

S. — Externally. 

Scabies 

(The "Itch") 

The eruption of scabies is localized chiefly in places where the skin 
is thinnest, i. e., the hands, the folds between the fingers, the flexor 



772 



DISEASES OF CHILDREN 



surfaces of the wrists, the anterior folds of the axilla, also the back 
and lower extremities. The characteristic skin lesion of scabies is the 
irregularly shaped, brownish-black ridge (cuniculus or burrow), the 
result of the burrowing process of the Acarus or Sarcoptes scabiei. 
The latter is the cause of scabies and can readily be demonstrated 
microscopically in the scrapings of the cuniculus. As the disease ad- 
vances, it frequently spreads over the entire body and gives rise to 




Fig. 233. — Animal parasites, A,, acarus scabiei, female (ventral surface) ; B, 
acarus scabiei, male (ventral surface); C, pediculus corporis; D, pediculus capitis; 
E, pediculus pubis. (Sutton: Diseases of the Skin.) 



a multiform eruption, consisting of papules, vesicles, pustules, and 
hemorrhagic spots (scratch marks). It is accompanied by violent itch- 
ing*, which is worse at night, when the patient is warm in bed. 

Treatment. — As the disease is highly contagious (conveyed through 
close bodily contact, clothes, underwear and bedding), it is advisable 



DISEASES OF THE SKIN 



77: 



to restrict the patient from too close mingling with other members of 
the family or outsiders. The patient's clothes, heel sheets, towels, etc., 
should be boiled and the other unwashable articles thoroughly disin- 
fected. Furthermore, all inmates of the house should be examined 
and, if necessary, treated for scabies, lest the disease will recur 
through renewed infection. The active treatment of scabies varies 
with the stage of the disease. Incipient scabies responds promptly 
to a few hot baths, thorough scrubbing of the affected skin with soft 
green soap and the inunction of sulphur ointment with 1 per cent 
carbolic acid. The management of advanced scabies with the same 
therapeutic measures is not quite as satisfactory. A number of rem- 
edies (strong ointments of carbolic acid, naphthol, creolin, etc.) have 




Fig. 234. — Scabies, in an infant. (Richard L. Sutton.) 



been suggested for such cases, but owing to their irritating qualities 
(upon the skin and kidneys) should be used with caution. The 
following combination will probably be found to do well in the ma- 
jority of cases : 

T£ Mentholis, 

Pulv. camphors aa, gr. x 0.65 

Olei cadini, 

Balsami Peruviani aa 3j 4 

Ung. sulphuris q.s. ad gij 60 

M. 
S. — To be applied in the evening after a hot soap bath. 



77^ 



DISEASES OF CHILDREN 



For the relief of itching we may also try the following ointment : 



li Mentholia gr. v 


0.3 


Olei Anisi m. xv 


1.0 


Ung. Petrolati I i 


30.0 


M. 


Sig. — Apply once or twice daily after soap bath. 



Tinea Trichophytina Capitis 

(RlNGWORM OF THE SCALP, HERPES TONSURANS ) 

Ringworm of the scalp is clue to the trichophyton fungus. It is 
highly contagious and often spreads with great rapidity and perti- 




Fig 235. — Trichophyton tonsurans — threads and chains of spores X 400. 

(After Bizzozero.) 




Fig. 236. — Large-spored ectothrix ringworm of scalp. (Eichard L. Sutton.) 

naeity in schools and children's homes where great numbers of inmates 
are crowded in comparatively small rooms. 

The eruption consists of ring-shaped, slightly elevated, scaly, red- 
dish, grayish, or greenish-yellow patches. The hair over the af- 



DISEASES OF THE SKIN 



775 



fected areas becomes brittle and loose and falls out, leaving behind 
bald shiny spots. 

At times the eruption is accompanied by severe local inflammation 
and exudation of a yellowish, viscid or gelatinous secretion — a condi- 
tion generally described as tinea kerion. 




Fig. 237. — Tinea tonsurans. (J. T. Shoemaker.) 

Treatment. — In the treatment of ringworm of the scalp it is essen- 
tial not only to prevent spreading of the disease from one child to the 
other, but also, to prevent autoinoculation from one part of the scalp 
to the other. This is best accomplished by sterilization (before and 
after using) of the hair clippers, scissors, combs, etc., and thorough 
scrubbing of the scalp with the tincture of green soap twice daily, 
and immediately after a hair cut. 

In an epidemic at an orphan asylum comprising nearly 400 cases of 
ringworm of the scalp, I found the following method of treatment 
exceedingly serviceable: 



9 



Aeidi carbolici, 
Olei petrolei 
Tinct. iodini, 
Olei ricini 
Olei rusei 



aa gij 

aa §iiiss 
q.s. ad 3xvj 



65 

110 
500 



776 DISEASES OF CHILDREN 

After clipping the hair close to the scalp this mixture is applied 
over the entire scalp — more thickly over the affected spots — by means 
of a painter's brush, once a day for five successive days. On the 
sixth day it is wiped off with a rag dipped in plain olive oil ; now the 
hair is clipped again and the scalp washed thoroughly but gently 
with green soap and a soft nailbrush, care being taken that all the 
scales and loose hair covering the scalp are removed. As a rule, no 
epilation is necessary. On the seventh day the mixture is reapplied 
as thickly as before and the whole process repeated regularly for 
three or four successive weeks, the length of time depending on the 
severity of the case. New hair will now be found to appear, and no 
trichophyton fungi will be discovered in the hair epilated for micro- 
scopic examination. 

These procedures are followed by a few day's application of a 10 
per cent sulphur ointment, and then by the use of the following prepa- 
ration for about two weeks: 



I> Eesorcini, 

Acicli salicyl. aa 3iv 

Alcoholis Siv 

Olei ricini q.s. ad. §xvj 



16 

120 
500 



This mixture considerably hastens the growth of the hair on the 
bald spots. In cases where isolation is impracticable or impossible, as 
often happens in private families, this resorcin mixture, daily applied, 
serves as an excellent substitute to prevent spreading of the affection. 
Tinea tonsurans is not to be confounded with tinea favosa, a hair 
affection caused by the Achorion Schonleinii, and characterized by 
sulphur-yellow, cup-shaped crusts or scutnla, penetrated by a hair or two. 

Tinea Trichophytina Corporis 

(Ringworm of the Body, Herpes Circinatus) 

Ringworm of the body begins as a small, scaly, circular spot which 
rapidly spreads peripherally and clears in the center, resembling a 
"ring" in shape. The rings frequently coalesce, forming serpiginous 
lesions. 

It is a trivial eruption and promptly yields to a few local applica- 
tions of the tincture of iodine, white precipitate ointment or glacial 
acetic acid (to be applied lightly once every other day). 

Molluscum Contagiosum 

Contagious molluscum is not rarely met in epidemic form in large 
institutions for children. The etiologic factor of the disease is as yet 
unknown. 



DISEASES OF THE SKIN 777 

The eruption appears principally upon the face, eyelids, neck and 
arms and consists of discrete, semiglobular, waxy-white, umbilicated, 
small (up to a split pea) wart-like elevations, with sebaceous con- 
tents. 

It is a benign affection and readily curable by ablation of the 
nodule or expression of its contents, and cauterization with tincture 
of iodine or 5 per cent salicylic acid in collodion. 

Telangiectases, Nevi and Angiomas 
(Birth Marks) 
Telangiectases are usually small, flat, superficial, radiating pink to 
bluish-red patches composed of a fine vascular net work. 

Nevi are bluish-red to dark blue, flat, or elevated neoplasms of con- 
siderable size. Nevi pigmentosi may be yellow, brown, blue, black, 
or grayish in color ; if covered by hair, they are spoken of as nevi pilosi. 
Angiomas are true vascular, spongy tumors raised above the skin 
and containing hollow spaces filled with blood. They have a tendency 




Fig. 238. — Vascular usevus. (Dr. E. L. Sutton.) 

to enlarge rapidly and there is danger of ultimate sarcomatous de- 
generation. On the other hand, some of them undergo spontaneous 
evolution. Hence, in cases which do not disfigure the patient and do 
not make rapid progress, it is often advisable to postpone treatment 
as long as possible. Small birth marks frequently disappear under 
the application (every third day) of a solution of corrosive sublimate 
in collodium (6 per cent); or a single drop of a 30 — volume of hydro- 
gen dioxide is applied by means of a glass rod twice daily. If these 
procedures fail, we have to resort to electrolysis or excision and liga- 
tion. 



778 DISEASES OF CHILDREN 

Combustio 

(Burns) 

In accordance with the degree of severity of the inflammation and 
destruction of tissue, burns are generally classified as follows : 

1. Dermatitis Ambustionis Erythematosa. — The surface is reddened, 
somewhat swollen and painful and the seat of small vesicles. 

2. Dermatitis Ambustionis Bullosa. — Blisters and bullae of variable 
size, marked edema and redness of the contiguous tissues. Severe 
pain. 

3. Dermatitis Ambustionis Escharotica. — Complete destruction of 
the integument and subcutaneous tissue, often also the muscular and 
fibrous tissues and even the bone. Surrounding skin blanched and 
markedly edematous. Sloughing of central portion. 

Extensive burns in children, even if only superficial, give rise to 
intense constitutional symptoms, such as shock, fever, vomiting, diar- 
rhea and sometimes convulsions. In an infant under observation a 
superficial burn of the neck was productive of serious edema glot- 
tidis, threatening asphyxia. Severe burns may prove fatal from shock 
within the first forty-eight hours or later from complicating erysipe- 
las, duodenal ulcer, pyemia, pneumonia or tetanus. 

Treatment. — Superficial burns generally improve rapidly under 
dressings with warm boracic acid solutions or carron oil. In order to 
avoid detachment of the skin on changing the dressings, it is advisable 
to cover the moist dressing with rubber tissue and bandage. Large 
blisters may be punctured with a sterile needle. After the inflam- 
matory symptoms have subsided the following ointment will prove 
very efficient. 

3 



Bismutlii subnitratis, 






Besorcini 


aa gr. x 


0.60 


Balsami Peruviani 


3ss 


2.00 


Ung. zinci oxidi 


£ 


30.00 


M. ft. ung. 







Exuberant, bleeding granulations may be reduced by daily paint- 
ing with a 2 per cent nitrate of silver solution. In large and deep 
burns the recently recommended method of treatment by means of 
paraffin wax, is undoubtedly the best. The mode of application is as 
follows : 

1. Melt the wax to fluidity, and while moderately hot, 

2. Paint raw surface of burn, until thoroughly covered. 

3. Apply thin layer of absorbent cotton. 



DISEASES OF THE SKIN 



779 



4. Paint absorbent cotton with a heavy coat of the wax. 

5. Cover with several layers of gauze, cotton and bandage. 

6. Change dressing daily or every other day. 

The wax should be melted in a sance pan over a free flame. A large 
camel's hair brush is used for painting. 

The constitutional symptoms should receive prompt attention. 
Bromides, small doses of codeine, and sterile camphorated oil hypo- 
dermically are indicated in the majority of cases. In the case re- 
ferred to an ice bag seemed to do most good to relieve the edema of 
the glottis. 

Congelatio 

(Frostbite; Chilblain) 

Frostbites are quite common in children who are more or less 
anemic. It is usually manifested by redness, heat, itching, smarting 
and burning. In severe cases blisters may develop, as a rule, from 
scratching, and end up in indolent ulcers. Frostbites usually affect 
the most exposed parts, such as the hands; feet, ears, cheeks, nose and 
lips, and are apt to return yearly with the advent of fall and winter. 
Chilblains of the fingers and toes should not be mistaken for acute in- 
flammatory rheumatism, which is a febrile affection. 

In the management of frostbites due consideration should be given 
to the underlying constitutional debility (administration of iron and 
codliver oil) and proper clothing suitable for the season of the year 
(flannel or silk underwear, etc.). Locally the parts should be bathed 
in hot water, and painted with balsam of Peru or ichthyol. A very 
useful ointment is the following : 



1$ Camphorse 




Oeosoti aa gr. xv 


1.0 


Balsami Peruviani 




Iclithvolis a a 3ss 


2.0 


Ung. petrolati §i 


30.0 


M. S- — To be applied once or twice a clay. 





INDEX 



Abdomen and its contents, 146 

anatomy of, 147 

enlargement of, 151 

retracted, in tuberculous meningitis, 
612 

size and shape of, 150 
Abdominal, parietes congenital defects 
of, 187 

pain, 151 

tuberculosis, 154 

tumors, 153 
Abnormal baby, 701 
Abscess, brain, in ear disease, 304 

cerebral, 621 

in spondylitis, 462 

peritonsillar, 294 

psoas, 466 

retropharyngeal, 302 

tubercular, in coxitis, 469 
Acarus, or sarcoptes scabiei, 772 
Acetonuria, 161, 522 

test of, 524 
Achondroplasia, 512 

differentiated from rachitis, 510 
Achorion Schonleinii, 776 
Acid intoxication, 522 
Acidosis, 522 

complicated by pyelitis, 523. 
Acids, mineral, 105 
Addison's disease, 556 
Adenie, 550 
Adenitis, 559 

in glandular fever, 405 

iu rubella, 364 

in scrofula, 459 

in tuberculosis, 446 
Adenoids, 298 

dangers and accidents after removal, 
300 

postoperative treatment of, 300 

removal of, 299 
Adhesio lingua?, 177 
Adipositas, 520 
Aerocele, 180 

Aestivoautumnal fever, 407 
Airing of baby, 6Q 
Albinism, 179 
Alcoholism and degeneracy, 762 



Albuminuria, 161 

cyclic, functional, lordotic, orthotic, 
582 

in nephritis, 574 
Alimentary tract, diseases of, 233 

malformations of. 183 
Allergy test, 87 

in asthma, 337 

in eczema, 762 
Alteratives, 105 
Amaurotic family idiocy, 716 

differentiated from microcephalus, 
709 
from rachiiis, 718 

juvenile form of, 717 

macular changes in eyes, 717 
Amebic dysentery, 413 
Amentia, 690 

classification of, 706 

diet in, 738 

etiology of, 690 

incentive training of, 741 

iu older children, 751 

medicinal treatment in, 746 

physical therapeutics in, 739 

prognosis of, 750 

surgical treatment of, 749 
Amnion navel, 188 
Amyatonia congenita, 204 
Amygdalitis, 293 
Amyloid disease of liver, 285 
Anemia, cerebral, 600 

pernicious, 551 

pseudoleukemia Von Jaksch, 549 

simple, 547 

splenic, 549 
Angina, 293 

differentiated from diphtheria, 294 
from influenza, 294 
from scarlatinal angina, 386 
Angina Ludovici, 387 
Angioma, 777 
Aniridia, 179 

Animation, suspended, 213 
Ankle-clonus, 171 
Ankyloblepharon, 178 
Ankyloglossia, 177 
Ankylostomiasis, 281 
Annulus migrans, 238 
Anodynes, 107 
Anophthalmus, 177 
Anthelmintics, 280 



781 



782 



INDEX 



Antibubonic scrum, 500 
Anticostive triad, 262 
Antidiphtheritic scrum, 75 
in diphtheria, 370 

in noma, 236 
in scarlatinal angina, 392 
Antidyscntcric scrum, 414 
Antimcningitis serum, 78 

intravenous injection of, 80 
in meningitis, 615 
Antipneumonic serum, 327 
Antipyretics, 106 
Antirheumatics, 106 
Antispasmodics, 107 

Antistreptococcic serum in scarlatina, 
393 
in malignant endocarditis, 536 
Antitetanic serum, 77 

in tetanus neonatorum, 227 
Anuria, 160, 586 
Anus, absence of, 185 

imperforate, 186 
Aortic, obstruction, 539 

regurgitation, 539 

stenosis, congenital, 528 
Aphthae, Bednar's, 234 

stomatitis, 234 
Apoplexia, neonatorum, 208 

in older children, 603 
Appendicitis, 269 

differentiated from acidosis, 523 

from intussusception, 267 

from peritonitis, 267 
Argyll Eobertson pupil, 121 
Aromatic baths, 92 

Arteritis and phlebitis umbilicalis, 228 
Arthritis, 418 

deformans, 420 

gonorrheal, 418 

rheumatic, 416 

rheumatoid, 418 

septic, 418 

syphilitic, 418, 421 

tuberculous, 421, 461 
Articular osteitis of hip, 466 
Artificial feeding of infants, 48 
Ascaris lumbricoides, 276 
Aspersion bath, 91 
Asphyxia neonatorum, 213 
Aspidium, in treatment of tape worm, 

281 
Aspiration, of cerebral ventricles, 209 

in pleural effusions, 334 

pneumonia, 369 
Assimilation, faulty, 55 

of casein, 56 

of sugar, 36 
Astasia abasia, 683 
Asthma, 337 

thymicum, 568 
Astringents, intestinal, 112 



Ataxia, diphtheritic, 369, 666 
hereditary, 657 

Atelectasis neonatorum, 213 
Athetosis, 619 

Athletics, 67 

in heart disease, 542 
Athrepsia, 501 
Atresia, ani, 186 

auris, 180 

esophagi, 183 

hymenalis, 197 

intestines, 183 

posterior nares, 179 

pupillae, 178 

recti, 186 

urethra?, 193 

vaginae, 197 

vulvae, 197 
Atrophy, infantile, 501 

of liver, acute yellow, 285 

myogenic, neural, spinal, 658 
Atropine, in pyloric stenosis, 248 
Attention, power of, 702 
Attitude of head, 118 
Auditory, meatus, absence of, 180 
Auricular, appendages, 179 
Auscultation, of heart, 131 

lungs, 129 



B 



Babinski's sign, 171 

in meningitis, 607 
Babies, mentally deficient, 690 
Bacterial vaccines, 81 
Bacteriuria, 164 
Banti's disease, 557 
Barley water, 49 
Barlow's disease, 514 

differentiated from rheumatic arthri- 
tis, 418 
Basedow's disease, 563 
Bathing of baby, 65 

Baths, medicated and nonmedicated, 90 
Bednar's aphthae, 234 
Bed-wetting, 587 
Bell's palsy, 663 
Beriberi, 517 

yeast in, 517 
Bier 's passive hyperemia, 471 
Binet-Simon mental tests, 753 
Biologic diagnosis and therapeutics, 71 
Birth, injuries, 207 

marks, 777 

paralysis, 208 
Bitter tonics, 103 
Black, death, 500 

measles, 361 

smallpox, 397 
Bladder, congenital malformations of, 
192 



INDEX 



783 



Bladder— Cont 'd 

diseases of, 584 

stones, 586 

tuberculosis, 457 
Bleeders, 552 
Bleeding from navel, 222 

from nose, 289 
Blindness, acquired, 223 

congenital, 177 
Blood, coagulation, 552 

count, differential, 547 

diseases, 546 

normal, 546 
Blue sickness, 525 
Bone, cyst of humerus, 478 

diseases, 204 

tuberculosis, 461 

tumors, 476 
Bothrioeephalus latus, 280 
Boundaries, of heart, 140 

lungs, 133 
Bowlegs, rachitic, 507 
Brachial paralysis, 211 
Bradycardia, in influenza, 353 
Brain, abscess, 304, 621 

anemia, 600 

degeneration, 708 

diseases, 596 

embolism, 604 

hemorrhage, 603 

hyperemia, 601 

localization, 602 

miniature, 707 

syphilis, 488 

tuberculosis, 452 

tumors, 645 

tumor differentiated from abscess, 623 
from gumma, 647 
from hysteria, 648 
from Jacksonian epilepsy, 648 
from tubercle, 647 
Bran baths, 92 
Branchial appendages, 181 
Branchiogenetic cysts, 181 
Break-bone fever, 410 
Breast, inflammation in the newborn, 232 

nipples, attention to, 44 

pump, 44 
Breast milk, 42 

analysis of, 45 
Breathing exercises, 439 
Breck's fever, 217 
Brissaud type of infantilism, 726 
Bronchial glands, tuberculosis of, 444 

tubes, diseases of, 314 
Bronchiectasis, 340 
Bronchitis, acute, 314 

capillary, 315 

chronic, 316 

fibrinous, 315 



Bronchopneumonia, 316; lobular, differ- 
entiated from lobar pneumonia, 
325 

Bronzed skin, 556 

Brudzinski's sign, in meningitis, 607 

Bubonic plague, 499 

Buhl's disease, 230 

Burns, 778 

treatment with paraffin wax, 778 

Buttermilk, 57 



Calculi, renal, 578 

vesical, 586 
Calmette-tuberculin-reaction, 83 
Calmuck type of Mongolian idiocy, 720 
Camp-fever, 404 
Cancrum oris, 234 
Capacity of infantile stomach, 55 
Capillary bronchitis, 315 
Caput succedaneum, 207 

differentiated from cephalhematoma, 
208 
Carbohydrates, digestion of, 32 

kinds of, 34 

metabolism of, 35 
Cardiac cases, exercise in, 542 
Cardiac cirrhosis of liver, 284 
Care of the, eyes, 64, 223 

newly born, 64 

teeth, 440 

umbilicus, 221 
Caries of vertebral column, 462 
Carpal bones, undevelopment in idiocy, 

728 
Casein, faulty digestion of, 56 

milk, 57 
Casts, in urine, 162 
Cataract, congenital, 178 
Cathartics, 111 
Caudal formations, 200 
Central, birth palsy, 208 

pneumonia, 321 
Cephalhematoma, 207 
Cephalocele, 174 

differentiated from cephalhematoma, 
208 
Cerebral, abscess, 621 

convulsions, differentiated from eclamp- 
sia, 670 

facial paralysis, differentiated from 
peripheral, 665 

hemorrhage, 208, 603, 714 

hyperemia, 601 

localization, 602 

paralysis, 601 

tumors, 645 
Cerebrospinal fluid, normal, 609 

pathologic, 611 

withdrawal by lumbar puncture, 610 
by puncture of subdural space, 210 



784 



INDEX 



Cervical rib, 181 

mistaken for spondylitis, 464 
Cervicitis, 589 

Chafing (intertrigo), 765 
Chaulmoogra oil, in leprosy, 499 

in tuberculosis, 451 
Cheiloschisis, 175 
Chest, abnormal shape of, 132 
Chicken-breast, 507 
Chicken pox, 394 
Chilblain, 779 
Chloroma, differentiated from scorbutus, 

516 
Chlorosis, 547 

Choked disc, in cerebral tumors, 646 
Cholera infantum, 250 
Chondrodystrophia foetalis, 512 
Chorea, 678 

electrica, 682 

insaniens, 680 

magna, 685 

minor, 678 

mollis, 679 

paralytic, 679 

rhythmica, 685 

vera, 678 
Choroidal tubercles, 453 
Chvostek's phenomenon in tetany, 673 
Chylothorax, 333 
Circular insanity, 760 
Circulatory system, diseases of, 525 
Circumcision, 194 
Circumference of, chest, 132 

head, 116 
Cirrhosis of liver, 284 

case report, 284 
Cleft, bladder, 192 

face, 175 

palate, 176 

vertebral column, 197 
Climatotherapy, 100 
Clothing of infant, 65 
Clubfoot, 202 

treatment of, 203 
Clubshaped fingers, in bronchiectasis, 340 

heart disease, 525 
Coccygeal tumors, 200 
Cold, compresses, 90 

effects of, 89 

packs, 89 

sponging, 89 
Cod4iver oil mixture, 451 

in tuberculosis, 451 

in rachitis, 512 
Colic, intestinal, 257 

renal, 578 
Colicystitis, 584 
Colitis, 253, 412 

Collapse of the lungs (atelectasis), 213 
Coloboma iridis, 179 



Colon, congenital dilatation and hyper- 
trophy, 184 
Colostrum, 44 

Combustio (see Burns), 778 
Communicable diseases, 345 

prevention of spreading of, 68 
Complement-fixation reaction in tubercu- 
losis, 84 
Compress, Priessnitz's, 90 
Condensed milk, 56 
Condyloma, syphilitic, 484 
Congelatio (see Frostbite), 779 
Congenital malformations (see Malforma- 
tions), 174 
Conjunctiva, tuberculin test of, 83 
Constipation, 157 

' ' anticostive triad" in, 262 

chronic, 259 

electricity in, 97 
Consumption, hasty, 442 
Contractures, of extremities, 167 

hysterical, 683 
Convulsions, 699 
Cor bovinum, 537 
Cord, umbilical, care of, 221 
Coryza, 288 
Cough, 138 
Cow's milk, 48 

composition of, 48 

feeding of, 48 

substitutes, 56 
Coxa vara, differentiated from coxitis, 

470 
Coxitis, tuberculous, 466 ; 

differentiated from rheumatism, 470 
Crab-louse, 771 
Cranial bones, 117 
Craniotabes, 505 

Cream, percentage in top milk, 49 
Crede's method of prevention of gonor- 
rheal ophthalmia, 223 
Creeping-pen, 67 
Creosote in tuberculosis, 451 
Cretinism, 721 

endemic, goitrous or sporadic, 563 

differentiated from Mongolism, 720 
from rachitis, 725 
Croup, diphtheritic, 367 

false, 309 

spasmodic, 309 
Croupous pneumonia, 320 
Crusta lactea, 762 
Cryptophthalmus, 178 
Cryptorchidism, 195 
Curvatures of, extremities, 166, 507 

spine, 463, 479 
Cyanosis, congenital, 525 

icterica, 229 
Cyclic, albuminuria, 582 

vomiting, 522 



INDEX 



785 



Cysticerci in the, brain, 648 

muscles, 425 
Cystitis, 584 
Cytodiagnosis, of cerebrospinal fluid, Gil 



Dactylitis in, frambesia, 496 

leprosy, 497 

syphilis, 492 

tuberculosis, 472 
Darwin's theory of heredity, modification 

of, 691 
Deaf-mutism, 387, 730 
Deafness, scarlatinal, 387 

syphilitic, 491 

tests of, 306 
Death, thymus, 568 
Dementia, 757 

paralytica, 759 

precox, 757 
Dengue, 410 
Dentitio diffieilis, 236 
Dermatitis, ambustionis, 778 

exfoliativa, neonatorum, 225 
Dextrocardia, 529 
Diabetes, foods in, 519 

insipidus, 520 

mellitus, 518 
Diacetic acid, test of, 524 

in urine, 161, 523 
Diagnostic, lines of thorax, 134 

significance of large abdomen, 151 
Diaphoretics, 110 
Diarrhea, 157 

and vomiting, 250 
Diastasis recti abdominis, 187 
Diazo-reaction in typhoid, 400 
Dietary in, amentia, 738 

normal baby, 60 
Differential diagnosis of, arthritides, 418 

diphtheria and angina, 374 

exanthematous diseases, 398 

meningitides, 613 

pneumonia and pleurisy, 324, 325, 333 

valvular heart diseases, 539 
Difficult, feeding, 55 

teething, 236 
Digestants, 103 
Digestibility of carbohydrates, 32 

of proteins, 26 
Digestive ferments in intestines, 33 
in pancreas, 32 
in saliva, 32 
in stomach, 32 
Diluents for cow 's milk, 49 
Diphtheria, 365 

antitoxin, 75, 221, 236, 370, 594 

croup, 367 

differential diagnosis, 374 

immunization, 75 



Diphtheria — Cont M 

intubation in, 376 

laryngeal, 367, 375 

nasal, 367 

omphalitis, 221 

paralysis, 369, 666 

pathology of, 365 

Schick's reaction in, 371 

serum, 74 

susceptibility to, 74 

toxin-antitoxin, 75 

tracheotomy in, 381 

treatment of, 370 

vulva?, 594 
Diplegia, 603 

spastica infantilis, 615 

with amentia, 713 
Diplopia, 121 

in lethargic encephalitis, 626 
Disinfection, 68 

solutions for, 70 
Dislocation of hip, congenital, 201 

septic, 220 
Disseminated sclerosis, 657 
Diuretics, 110 
Diverticulum, Meckel 's, 191 
Dome-shaped skull, 708 
Double jointed, 508 
Dropsy of the, brain, 596 

nephritis, 573 
Dry milk, 58 

manufacture of, 58 
Duehenne-Erb paralysis, 211 
Ductless-glands, diseases of, 546 
Ductus, arteriosus Botalli, persistence 
of, 526 

omphalomesentericus, 190 
Dukes' disease, 394 
Dysentery, 412 

serum, 414 
Dyspepsia, 248 

classification of, 248 
Dyspituitarism and hydrocephalus, 600 
Dystonia musculorum deformans, 688 
Dystrophia, adiposogenitalis, 570 

muscularis, 659 
Dysuria, 586 



Ear, affections, 303 

appendages, 122 

foreign bodies in, 303 

malformations, 179 

semeiology of, 122 
Eclampsia, infantile, 669 

differentiated from epilepsy, 669 
from meningitis, 613 
from uremia, 670 
Ecthyma, 768 



786 



INDEX 



Ectopia, cordis, 529 

vesicas, 192 

viseerum, 188 
Eczema, 7G1 
Edema, of eyelids, 120 

glottidis, 313 

scleredema, 218 
Eiweiss milk, 57 
Electricity, 96 

Embolism of cerebral arteries, 604 
Emetics, 109 
Emphysema, pulmonum, 339 

cutis (see Pneumohypoderma), 344. 
Empyema, 331 

necessitatis, 332 
Encephalitis, epidemic, lethargic, 624 

differentiated from meningitis and 
brain tumor, 623 

nonsuppurative, 620 

suppurative, 621 
Encephalocele, 174 
Enchondroma, 174 
Endocarditis, acute, 533 

chronic, 536 

differentiated from pericarditis, 536 

malignant, 535 
English disease (see Eachitis), 503 
Enteralgia, 257 
Enteric fever, 399 
Enteritis, 248 
Enteroclysis, 94 
Enterocolitis, 248 
Enuresis, 587 

electricity in, 97 
Eosinophilia in, asthma, 338 

scarlatina, 388 
Epidemic hemoglobinuria with icterus, 

229 
Epilepsy, 649 

differentiated from eclampsia, 669 
from hysteroepilepsy, 686 

Jacksonian, 650 

nutans. 651 

procursiva, 651 

with idiocy, 712 
Epiphyseolysis in, osteomyelitis, 475 

rachitis, 508 
Epiphysitis, syphilitic, 485 
Epispadias, 193 
Epistaxis, 289 
Epithelial pearls, 234 

differentiated from ulcerative stoma- 
titis, 234 
Erb's, paralysis, 212 

sign of tetany, 673 
Eruptive fevers, differential table, 398 
Erysipelas, neonatorum, 229 

in omphalitis, 221 
Erythema nodosum, 424 
Escherich's incubator room, 216 
Esophagitis, 239 



Esophagus, diseases of, 239 

stenosis, congenital, 183 
Eustachian tube, catarrh of, 303 
Examination of the patient, 115 
Exanthematous diseases, differential 

chart, 398 
Exercise, 66 

in heart diseases, 542 

in lung diseases, 439 
Exfoliative dermatitis, 225 
Exomphalos, 188 
Exophthalmic goiter, 563 
Exostoses, multiple, 426 
Expectorants, 110 
Expectoration, 138 
Extremities, abnormalities of, 166, 201 

curvatures of, 166 

muscular contractures of, 167 

muscular weakness of, 167 

paralysis of, 168, 601 

shortness of, 166 

spasmodic movements of, 167 

tumefactions of, 166 
Exudative diathesis, 52F 
Eyes, appearance in disease, 120 

care of in the newly born, 64, 223 

changes in amaurotic family idiocy, 717 

changes in meningitis, 608 

congenital, absence of, 177 
Eyelids, semeiology of, 120 



Face, semeiology of, 118 
Facial, hemiatrophy, 665 

paralysis, electricity in, 98 
in poliomyelitis, 635 
nuclear, 664 
peripheral, 210, 663 
Family, history in disease, 115 

idiocy, 716 

splenomegaly, 558 
Faradic current, 97 
Fat, breast milk, 46 

in stools, 39 

metabolism, 37 

percentage in cow's milk, 48 

retention, 38 

vegetable, 41 
Fatty, degeneration in the newborn, 
acute, 230 

liver, 285 
Febris, intermittens, 406 

recurrens, 404 

rubra, 382 
Feeble vitality of the newborn, 213 

treatment of, 216 
Feeding, of infants, artificial cow's 
milk, 48 

mother's milk, 42 

of older children, 60 

scheme, 53 



INDEX 



787 



Fetor ex ore, 124 

Fever charts of, endocarditis maligna, 
534 

influenza, 350 

rubella, 363 

rubeola, 359 

scarlatina, 400 

tuberculous meningitis, 612 

typhoid, 400 
Fever, glandular, 405 

malarial, 406 

relapsing, 404 

rheumatic, 414 

typhoid, 399 

typhus, 404 

yellow, 411. 
Filatov-Koplik spots, 359 
Fistula colli congenita, 180 
Fits, epileptic, 649 
Flatulence, colic, 257 
Flaxed poultice, in pneumonia, 318 
Flexner's serum in, dysentery, 414 

meningitis, 615 
Floating kidney, 192 
Flu (see Influenza), 345 
Fontanelles, 117 

Foods, allergy or idiosvncrasy tests of, 
87 

composition of, 62 

in diabetes, 519 

in infants, 42, 48, 60, 738 
Foramen ovale, persistence of, 526 
Foreign bodies in, ear, 303 

esophagus, 239 

intestines, 266 

larynx, 314 

nose, 290 
Formaldehyd-potassium -permanganate 

fumigation, 71 
Fourth disease, 394 
Fragilitas ossium, 205 
Frambesia. 496 
Friedreich 's ataxia, 657 
Frohlieh's syndrome, 570 
Frost bite, 779 
Fumigation, 71 

Functional diseases in the newborn, 231 
Funnel shaped chest, acquired in ade- 
noids, 297 

and rickets, 507 

congenital, 182 
Furunculosis of ear, 303 



Gait, semeiology of, 170 
Galvanic current, 96 
Gangrene of, genitalia, 594 

lungs, 341 

navel, 221 

skin in varicella, 395 



Gastric sedatives, 112 
Gastritis, 250 
Gastroenteritis, acute, 248 

chronic, 2.":; 

subacute, 253 

tetanism in, 254 

treatment of, 254 
Gavage, 216, 615 

Genitalia, congenital malformations of, 
164 

diseases of, 589 
Genu, valgum, 508 

varum, 508 
Geographic tongue, 238 
German measles, 363 
Gibbus (see Kyphosis), 465 
Glands, bronchial, tuberculosis of, 444 
Glandular, fever, 405 

therapy, 113 
Glossitis, 238 
Glottis, edema of, 313 

spasm of, 677 
Glycosuria, 160, 518 
Goiter, 561 

exophthalmic, 563 
Gonorrheal, arthritis, 418 

differentiated from rheumatic arthri- 
tis, 418 

ophthalmia, 222 

proctitis, 592 

vulvovaginitis, 591 
Granuloma of the umbilicus, 222 
Graves' disease, 563 
Green, sickness, 547 

tumor. 516 
Grip, 345 
Groats water, 49 
Grocei's sis-n, in pleurisy, 329 
Gumma, 492 
Gums, semeiology of, 124 

bleeding from, 514 
Gymnastics, in heart disease, 542 



IT 



Habit, spasm, 681 

Half -cretin, 724 

Hand-trident, in achondroplasia, 511 

in cretinism, 722 
Hare lip, 175 
Head, attitude of, in disease, 118 

circumference, 116 

louse, 772 

nodding, 682 

semeiology of, 116 
Headache, sick, 653 

in brain tumor, 645 
Health resorts, 100 
Hearing, defective, 122, 701 

tests^of, 306 



788 



INDEX 



Heart, apex, 142 
boundaries, 140 
dilatation, 537 
diseases, acquired, 529 
diseases, congenital, 525 
dullness, 140, 144 
exercises in disease of, 542 
hypertrophy, 537 
murmurs, 143 
normal, 140 

paralysis in diphtheria, 369 
percussion of, 131 
sedatives, 109 
skiagrams, 140, 537 
sounds, 143 
stimulants, 108 
transposition of, 529 
valvular disease of the, 536 
Heat, effects of, 88 
Hebephrenia, 757 
Hectic fever, 446 
Height, 173 

Heine-Medin-disease, 627 
Hematoma, sternocleidomastoidei, 208 
Hematuria, semeiology of, 162 
Hemianopsia, semeiology of, 121 
Hemiatrophy, facial, 665 
Hemichorea, 679 
Hemicrania, 653 
Hemiplegia, 601 
double, 603 

spastica infantilis, 618, 637 
Hemoglobinuria, 581 
paroxysmal, 582 
with icterus, epidemic, 229 
Hemophilia {see Hemorrhea), 552 
Hemoptysis, 446 
Hemorrhage, cerebral, 208, 603 
cutaneous, 554 
in influenza, 351 
intestinal, 412 
intracranial, 208, 603 
meningeal, 603 
nasal/ 289 

postoperative, after adenectomy or ton- 
sillectomy, 297 
pulmonary, 446 
rectal, 257 
renal, 583 
spinal, 655 
subperiosteal, 515 
umbilical, 222 
Hemorrhea, acquisita, 553 
congenita, 552 
differentiated from exanthemata, scurvy 

and septic purpura, 555 
treatment of, 553, 555 
Hemorrhoids, differentiated from procti- 
tis, 257 
Hemothorax, 343 
Henoch's purpura, 555 



Hepatitis, interstitial, syphilitic, 486 
Hereditary ataxia, 657 

atrophy, progressive, muscular, 658 
Heredity, in mental deficiencies, perma- 
nent and temporary, 691 
Hernia?, 151 
cerebral, 174 
inguinal, differentiated from psoas 

abscess, 466 
spinal, 197 
umbilical, 197 
Herpes, cireinatus, 776 
tonsurans, 774 
zoster, 767 
Herter's infantilism, 727 
Hip, congenital dislocation of, 201 
joint disease tuberculous, 466 
malformations, 201 
Hirschsprung's disease, 155, 184 
History of patient, the taking of, 115 
Hives, the, 764 
Hodgkin's disease, 550 
Holt 's milk testing set, 45 
Home-made liquid capsules, 104 
Home-modification of cow's milk, 51 
Hookworm disease, 281 

thymol in, 282 
Horseshoe kidney, 192 
Hot baths, 91 
Hutchinson's, teeth, 490 
triad of syphilis, 490 
Hydatid cyst of liver, differentiated 
from abscess, tumor and pleuri- 
tic effusion, 286 
Hydrocele, 195 
Hydrocephalocele, 174 
Hydrocephaloid, 251, 600 
Hydrocephalus, 117, 452, 596, 710 
Hydronephrosis, 580 
Hydrotherapy, 88 

Hydrothorax, differentiated from pleur- 
isy, 333 
Hygiene and sanitation, 64 

in amentia, 737 
Hygroma, eysticum colli congenitum, 181 
differentiated from goiter, 562 
sacral, 200 
Hymen, atresia of, 197 
Hyperemia, cerebral, 601 

passive, Bier's method of treatment, 
471 
Hyperidrosis, in rachitis, 506 

in German measles, 363 
Hyperpituitaria, 570 
Hypertrophy of, brain, 712 
colon, 184 
differentiated from pericarditis with 

effusion, 532 
heart, 540 
tonsils, 296 



INDEX 



789 



Hypnotics, 107 
Hypodermoclysis, 94 

Hypopituitaria, 570 
Hypospadias, 193 
Hypothyroidism, 563 
Hysteria, 682 

differentiated from epilepsy, 686 

electricity in, 98 

phantom abdominal tumor in, 684 
Hysterical contracture of lower extremi- 
ty, differentiated from coxitis, 
683 
Hysteroepilepsy, 686 



Icterus, catarrhal, 283 

epidemic with hemoglobinuria, 229 

neonatorum, 231 
Idiocy, 690 

amaurotic, 702, 716 

Calmuek type, 720 

classification of, 706 

cretinic, 721 

diagnosis of, 696 

epileptic, 751 

etiology and pathology of, 690 

hydrocephalic, 710 

mental tests in, 705 

microcephalic, 702 

Mongolian, 718 

paralytic, 712 

prophylactic and active treatment of, 
732 
Idiotic status or attitude, 702 
Ileocolitis, epidemic, 412 
Imbecility, 752, 753 
Imitation power of, in idiocy, 703 
Immunity, 26, 71 
Immigration, 71 
Impetigo, contagiosa, 769 
Incentive training in idiocy, 739 
Incontinence of urine, 587 
Incubator room, 216 
Indigestion, 248 
Infant, feeding, 26 

stools, 55, 158 
Infantile, atrophy, 501 

muscular atrophy, 659 

paralysis, 627 
Infantilism, 726 

Infarct, uric acid, in the newborn, 231 
Influenza, 345 

differentiated from typhoid fever, 402 

pathology of, 346 

vaccine in, 354 
Inhalations, medicated, 311, 373, 433 
Inherent strength, 25 
Injections, intestinal, 94 

intraperitoneal, 95, 251 
Insanity, 757 



Intelligence, defective in idiocy, 704 

normal, 698 
Intermittent fever, -106 
Intertrigo, 7<>5 
Intestines, atony of, 147 

catarrh of, 248 

congenital malformations of, 183 

differentiated from strangulation, 267 

diseases of, 248 

intussusceptions of, 264 

syphilis of, 488 

tuberculosis of, 453 

worms in, 276 
Intubation, in diphtheria, 376 

feeding after, 380 
Intussusception, 264 

differentiated from prolapsus recti, 264 
Intravenous injection of serum, in menin- 
gitis, 80 
Invagination, intestinal, 264 
Irideremia, 179 
Iridoschisma, 179 
Iris, fissure of, 179 
Irrigations, intestinal, 93, 94 
Ischuria, 586 
Isolation of patient, 69 
Itch, the, 771 



Jacksonian epilepsy, 650 
Jail-fever, 404 
Jaundice, catarrhal, 283 

epidemic, 229 

in the newborn, 231 
Juvenile form of, amaurotic idiocy, 717 

muscular atrophy, 659 



K 



Kakke (see Beriberi), 517 
Karell's diet in, heart disease, 545 

nephritis, 578 
Katatonia, 757 
Keratitis, interstitial, syphilitic, 491 

phlyctenular, 459 
Kernig's sign of meningitis, 171, 607 
Kidney, anatomy of, 49 

congenital malformations of, 192 

diseases of, 572 

stones in, 578 

tuberculosis of, 457 

tumors of the, 582 
Knee jerk, 171 

joint disease, 470 
Knock-knees, 508 
Koplik-spots in measles, 359 
Kyphosis, rachitic, 507 

tuberculous, 465 



790 



INDEX 



L 

Laboratory milk, 10 I 
Labyrinth disease, 308 

Landry \s paralysis, 635 

differentiated from multiple neuritis 
6G8 
Laryngeal tumors, 313 
Laryngismus stridulus, 309 
Laryngitis, acute, 308 
catarrhal, 309 
chronic, 311 
diphtheritic, 367 
differential diagnosis, 310 

between catarrhal, syphilitic and tu- 
berculous laryngitis, 312 
membranous, nondiphtheritic, 309 
spasmodic, 309 
stridula, 309 
Laryngocele, 180 
Laryngospasmus, 677 
Larynx, foreign bodies in, 314 

malformations of, 180 
Lavage, 93 
Laxatives, 111 

Leichtenstern's sign of meningitis, 608 
Length of child, 171, 173 
Leueocythemia, 550 
Leukemia, 550 
Leprosy, 497 

chaulmoogra oil in, 499 
Lethargic, encephalitis, 625 

differential diagnosis from similar af- 
fections, 626 
Lice, body and head, 776, 777 
Lichen strophulus, 768 
Lien mobilis, 556 
Lingua geographica, 238 
Lipodystrophia, progressiva, 661 
Lipomatosis universalis, 520 
Lips, semeiology of, 123 
Little's disease, 615 
with amentia, 713 
Liver, abscess, 285 

abscess differentiated from pleurisy, 

286 
amyloid degeneration of, 285 
anatomy of, 147 
cirrhosis of, 284 
fatty, 285 
sugar coated, 285 
tumors of, 286 
Lobar, pneumonia, 320 
Lobular pneumonia, 316 
Lordosis, 481 

albuminuria in, 582 
Lumbar puncture, 610 
in meningitis, 610 
in poliomyelitis, 642 
in scarlatinal uremia, 392 



Lungs, auscultation of, 129 

boundaries of, 134 

collapse, congenital, of, 213 

diseases, 314 

percussion of, 130 
Luschka's tonsil (sec Adenoids), 298 
Luxatio coxae congenita, 201 
Lymphadenitis, 559 

tuberculosis, 458 
Lymphadenoma, 550 
Lymphangioma cystieum, 181 
Lymphatic glands, semeiology of, 129 

M 

McEwen sign in meningitis, 608 
Macrocephalus, differentiated from hy- 
drocephalus, 712 
Microglossia, 177, 726 
Microstomia, 76 
Maculur changes in amaurotic family 

idiocy, 717 
Malaria, 405, 408 

differentiated from miliary tuberculo- 
sis, 443 
from typhoid, 402 
Malformations, congenital, of the ali- 
mentary tract, 183 
bladder, 192 
brain, 174 
ears, 179 
extremities, 201 
face, 175 

genitourinary tract, 192 
head, 174 
heart, 525 
larynx, 180 
mouth, 177 
neck, 180 
nose, 179 
thorax, 182 
tongue, 177 
trachea, 180 
vertebral column, 197 
Malt, baths, 92 
soup, 56, 503 
Mania, 759 
Marasmus, 501 

differentiated from miliary tuberculo- 
sis, 444 
Massage, 99 

Mastitis neonatorum, 232 
Mastoiditis, 303 
Masturbation, 593 

Materia Medica and therapeutics, 88, 101 
Measles, 358 

German or Liberty, 363 
Meckel's diverticulum, 191 
Medicated baths, 91 
Medication, select, palatable, 101 
Megacolon congenitum, 184 



INDEX 



791 



Melancholia, 759 

Melena neonatorum, 229 

Meloschisis, 176 

Meningeal hemorrhage, 208, 603 

Meningitis, acute, 605 

cerebrospinal, 605 

cerebrospinal fluid in, 609 

differential diagnosis, 613 

Flexner 's serum in, 609 

in mastoid disease, 304 

serosa, 598 

spinal, 655 

syphilitic, 614 

tuberculous, 605, 614 
Meningocele, 174 

spinal, 197 
Menstruatio precox, 594 
Mental, deficiencies in infants, 690 

diseases in older children, 757 

retardation, 728 

stigmata of degeneration, 697 

tests, 705, 753 
Mercurial baths, 92 
Mesocardia, 432 

Metabolism, of carbohydrates and fats, 
35, 37 

disturbances of, 501 
Microcephalus with idiocy, 702, 707 

differentiated from Mongolism, 720 
Micromelia, 512 
Microphthalmus, 178 
Microscopy of human milk, 42 
Microstomia, 177 
Migraine, 653 
Miliaria, 768 
Miliary tuberculosis, 442 

differentiated from lobar pneumonia, 
325 

from typhoid fever, 402 

skiagram of, 443 
Milk, casein, 57 

composition of cow's and human, 48 

condensed, 56 

cow's feeding of, 48 

dry, 58 

eiweiss, 57 

formulas, 53 

home modified, 52 

laboratory, 51 

pasteurized, 51 

peptonized, 59 

protein, 57 

sterilized, 51 

substitutes of, 56 

top, 49 

woman's, 42 
Mineral acids, 105 
Miniature brain, 702 
Mitral heart disease, 539 
Moeller-Barlow 's disease (see Scurvy), 
514 



Alolhisciini contagiosum, 776 
Mongolian idiocy, 718 

differentiated from amaurotic idiocy, 
718 
from cretinism, 720, 725 
from microcephalus, 709 
Monoplegia, 603 
Monorchidism, 195 

Moramentia (retarded mentality), 728 
Morbilli, 358 
Morbus, Addisoni, 556 

coeruleus, 525 

coxarius, 466 

maculosus Werlhofii, 554 
Moron, 753 

Moro's tuberculin test, 38 
Mosquitoes as carriers of, dengue, 410 

malaria, 405 

yellow fever, 411 
Motion, voluntary power of in amentia, 

703 
Mouth, diseases of, 233 

semeiology of, 123 

wash, 235 
Multiple, exostoses, 426 

neuritis, 98, 665 

sclerosis, 657 
Mumps, 427 

secondary, 238 
Muscles, atrophies, 658 

congenital affections of, 204 

spasms of, 167 

thoracic, defects of, 183 

weakness of, 167 
Mustard, baths, 92 

water compresses, in pneumonia, 326 
Myatonia congenita, (Oppenheim), 204 
Myelitis, 656 
Myelocystocele, 197 
Myelomeningocele, 197 
Myocarditis, 529 
Myositis, 425 

ossificans, 426 

scarlatinal, 387 
Myotonia congenita (Thomsen), 205 
Myxidiocy, 563, 721 



N 



Nasal, discharge, 122 

hemorrhage, 289 

obstructions, congenital, 179 

tuberculin test, 83 
Nauheim baths, 91 
Navel, affections of, 219 
Neck, semeiology of, 129 

rigidity of (see Opisthotonos), 607 
Nephritis, acute, 572 

chronic, 577 

diphtheritic, 368 

scarlatinal, 388 



792 



[NDEX 



Nephritis — Cont \\ 

varicellosa, 395 
Nephrolithiasis, 578 
Nerve diseases, 596 
Nettle rash, 764 
Neuritis, differential diagnosis, 668 

diphtheritic, multiple, 665 
Nevus, 777 
Newborn, care of, 64 

diseases of, 213 

feeble vitality of, 213 

injuries of, 207 

whooping' cough in the, 434 
Night, terrors, 654 

sweats, 447 
Noguchi's, Wassermann reaction in syph- 
ilis, 85 

Leptospira icteroides, in yellow fever, 
411 
Noma, faciei, 234 

in measles, 361 

vulvae, 594 
Nona, (see Lethargic Encephalitis), 624 
Nose, bleeding, 289 

diseases, 288 

malformations of, 179 

semeiology of, 123 
Nursery, 67 
Nursing, maternal, 43 

wet nursing, 46 
Nutrition, 26 
Nystagmus, semeiology of, 120 







Oatmeal water, 49 

Obesity, 520 

Obstetric paralysis, brachial, 211 

facial, 210 
O'Dwyer's intubation set, 378 
Oliguria, 160 
Omphalitis, 219 
Omphalocele, 188 

Omphalomesenteric duct, persistent, 190 
Omphalorrhagia, 222 
Onanism, 593 

One-day-fever (see Glandular fever), 405 
Ophthalmia, gonorrheal, 592 

strumous, 459 
Ophthalmoblennorrhea neonatorum, 222 
Opisthotonos, 607 

Optic neuritis in cerebral tumors, 646 
Organotherapy, 113 
Orthotic albuminuria, 582 
Osteitis, 473 

of hip, 466 
Osteogenesis imperfecta, 205, 511 
Osteomyelitis, 473 

differentiated from rheumatic, 419 

syphilitic, 491 

tuberculous, 461 



Otitis, 303 

Oxyuris vermicularis, 276 

Ozena, 289 



Pack, cold, 89 

vapor, 89 
Palatable medication, 101 
Palate, semeiology of, 126 

malformations, of, 176 
Papilloma, laryngeal, 313 
Paraffin wax in burns, 778 
Paralysis, brachial, 211 

cerebral, 208, 601 

diphtheritic, 368 

facial, nuclear, 664 

facial, peripheral, 210, 663 

infantile, 627 

of extremities, 167 

pseudobulbar, 603 

pseudohypertrophic, 659 

spastic, 618 
Paralytic, amentia, 712 

dementia, 759 

idiot, 714 
Paramyoclonus multiplex, 682 
Paraplegia, 656, 657 
Parasites, intestinal (see worms), 276 
Parasituria, 164 
Parasyphilis, 490 

Parathyroid gland (see Organotherapy) 
113 

in amentia, 747 

injury in pertussis, 434 

injury in tetany, 673 
Parotitis, epidemic, 427 

secondary, 238 
Parrot's, nodes, 486 

pseudoparalysis in syphilis, 486 
Passive hyperemia, Bier's method, 471 
Pasteurization of milk, 51 
Pavor nocturnus, 654 
Pearls, epithelial, in stomatitis, 234 
Pectus carinatum, in rachitis, 507 
P'edatrophy, 501 
Pediculosis, capitis, 770 

corporis, 771 

illustrated, 772 

pubis, 771 
Peliosis rheumatica, 424 

differentiated from scorbutus, 516 
Pellagra, 517 
Pemphigus, neonatorum, 224 

syphilitic, 484 
Peptonized milk, 59 
Peptonuria, semeiology of, 163 
Perception, poAver of, in amentia, 703 
Percussion, of thorax, 129 

resonance abnormal, 137 



INDEX 



793 



Pericarditic pseudocirrhosis (Pick's dis- 
ease), 285 
Pericarditis, 530 

differentiated from endocarditis, 536 
from pleurisy, 333 

purulent, 532 
Periosteal reflex, 171 
Periostitis, 473 

Peripheral, facial palsy, 210, 663 
Peritonitis, acute, 275 

differentiated from, intussusception, 
267 
rachitic abdominal enlargement, 155 

tuberculous, 453 
Peritonsillar abscess, 294 
Perityphlitis, 269 
Pernicious anemia, 551 

serum treatment of, 551 
Perspiration, excessive in, German meas- 
les, 364 

rickets, 506 
Pertussis, 429 

in the newly born, 434 
Pestis Americana {see Yellow Fever), 
411 

bubonica, 499 
Pharyngitis, 292 

Phenolsulphonephthalein test in nephri- 
tis, 578 
Phimosis, 193 
Phlyctenular keratitis, 459 
Phthisis pulmonum, 444 

differentiated from bronchiectasis, 340 
Physical, examination of the patient, 115 

therapeutics in amentia, 739 
Pick's disease, 285 
Pineal gland extract, 113, 747 
Pin-worms, 276 
Pituitary gland, diseases of, 570 

extract, 113, 747 
Plague, bubonic, 499 
Plasmodium malariae, 405, plate XI 
Pleuritis, 327 

chylous, 333 . 

differentiated from liver abscess, 286 
from pneumonia, 333 

dry, 327 

hemorrhagic, 330 

purulent, 331 

serous, 330 

tuberculous, 330 

with effusion, 328 
Pneumohypoderma {see Emphysema Cu- 
tis), 344 
Pneumonia, alba, 482 

aspiration, 369 

croupous, 320 

flaxseed poultice in, 318 



Pneumonia — Cont'd 

lobar, 320 

differentiated from bronchopneumo- 
nia and miliary tuberculosis, 325 
from meningitis, 613 
from pleurisy, 333 
pathology of, 320 

lobular, 316 
Pneumothorax, 343 

artificial in pulmonary tuberculosis, 
452 
Polioencephalitis, 627 

Struempell type, 618, 637 
Poliomyelitis, 627 

diagnosis, 640 

differentiated from multiple neuritis, 
668 

electricity in, 98 

pathology of, 630 

serum in, 642 

treatment, medical and surgical of, 641 
Polyarthritis, acute, 414 
Polymyositis, 425 
Polyneuritis, 665 

epidemic {see Beriberi), 517 
Polyuria, 520 

semeiology of, 159 
Pot-belly in rickets, 509 
Pott's disease, 462 
Poultice of flaxseed meal, in pneumonia, 

318 
Power of resistance, 26 
Precocious puberty, 571 
Premature birth, 214 

management of, 216 
Prepuce, congenital malformations of, 

193 
Prevention and control of disease, 25 
Prickly heat, 668 
Priessnitz 's compress, 90 
Proctitis, 257 

gonorrheal, 592 
Progressive, muscular atrophy, 658 

torsion spasm, 688 
Prolapsus ani et recti, 263 

in rickets, 509 
Prophylaxis, 68 

in amentia, 732 
Protein, milk, 57 

digestibility of, 26 

faulty digestion of, 56 
Prurigo, 764 
Pseudofurunculosis, 768 
Pseudohypertrophic paralysis, 659 
Pseudoleukemia, infantum, 549 

lymphatica, 550 
Pseudomeningocele, 174 
Pseudoparalysis, in rickets, 509 

in scurvy, 515 

in syphilis, 486 
Pseudotetanus, 676 



794 



INDEX 



Psoas abscess, 466 
Psoriasis, 766 
Puberty precocious, 571 
Pulmonary artery, stenosis, congenital 
of, 528 

valve, affections of, 540 
Pulsation in neck, someiology of, 129 
Pulse rate, semciology of, 142, 145 
Pupils, semeiology of, 120 
Purgatives, 111 

Purpura fulminans, hemorrhagic, simple 
and Werlhof 's, 554, 555 

rheumatic, 424 

differentiated from scorbutus, 516 

vaccina toria, 73 
Purulent ophthalmia, 222 
Pyelitis, 580, 584 

with acidosis, 523 
P'yelocystitis, 584 
Pyelonephritis, 580 
Pyloric stenosis, 242 

medical and surgical treatment, 245 
Pylorospasm, 242 
Pyopneumothorax, 343 
Pyothorax, 331 
Pyuria, 163 

Q 

Quarantine, 68 

Quinine in, malaria, 408 

whooping cough, 433 
Quinsy, 293 

R 

Rachitis, 503 

abdominal enlargement in, differenti- 
ated from tuberculous peritoni- 
tis, 154 
acute {see Scorbutus), 514 
amaurotic family idiocy, 718 
cod liver oil in, 512 
differentiated from achondroplasia, 510 
from cretinism, 725 
from hydrocephalus, 711 
fetal, 512 

kyphosis in, differentiated from spon- 
dylitis, 507 
osteogenesis imperfecta, 511 
Ranula, 237 

Rectum, discharges from, semeiology of, 
165 
malformations of, 186 
prolapse of, 263 

differentiated from intussusception, 
254 
Recurrent, cyclic, vomiting {see Acid- 
osis), 522 
Reflexes of tendons, 171 
Relapsing fever, 404 
Remittent fever, 407 

differentiated from meningitis, 614 



Ren mobilis, 192 
Renal, calculi, 578 

hemorrhage, 162, 583 
Resorcin-alcohol, in scarlatinal angina, 

391 
Respirations, semciology of, 134 
Respiratory, diseases, 287 

sounds, 136 
Retropharyngeal, abscess, 301 
Rheumatic fever, 414 

torticollis, 417 
Rheumatism, 414 

acute, 414 

articular, 414 

chronic, 420 

differential diagnosis, 418 

electricity in, 98 

muscular, 416 

nodosus, 424 

scarlatinal, 387 
Rheumatoid arthritis, 420 
Rhinitis, 288 

diphtheritic, 367 
Ribs, cervical, 181 

cervical, mistaken for spondylitis, 464 

semeiology of, 182 
Rice water, 49 
Rickets {see Rachitis), 503 
Rigidity, of limbs {see Little's disease), 
615 

of the neck, 129 

in meningitis, 607 
Ringworm, of body, 776 

of head, 774 
Rocky Mountain fever, 399, 419- 
Roentgen-ray diagnosis in pleurisy, 329 
Roseola, epidemic, 363 
Rotheln, 363 
Rubella, 363 
Rubeola, 358 . 



S 



Sacral tumors, 200 

Saint Vitus' dance, 563 

Salaamkrampf {see Epilepsia nutans), 

651 
Saline injections, 94 

hypodermic, intraperitoneal, intrasinus 

and intravenous, 95 
Saliva, semeiology of, 128 
Salivary glands, diseases of, 237 
Salivation, 237 
Salvarsan, its administration in syphilis, 

495 
Sanitation, 64 
Sarcoma of, bones, 476 

kidney, 583 
Sarcomphalos, 222 
Scapulas, abnormal posture of, 133 



INDEX 



795 



Scarlatina, 382 

maligna, gravissima s. fulminans, 389 

seasonal prevalence of, 383 
Scarlatinal, angina, 386 

differentiated from diphtheria, 375 

nephritis, 388 

otitis, 387 

rheumatism, 387 

uremia, 388 
Scheme for infant feeding, 53 
Schick's reaction in diphtheria, 74 
Schoenlein 's disease (see Peliosis Bheu- 

matica), 424 
Scissors gait (see Little's disease), 615 
Scleredema neonatorum, 218 
Sclerema neonatorum, 218 
Sclerosis, disseminated, multiple, 657 
Scoliosis, 479 

rachitic, 507 

in poliomyelitis, 637 
Scorbutus, 514 

differentiated from chloroma, epiphysi- 
tis syphilitica, osteomyelitis, pel- 
iosis rheum atica, purpura hem- 
orrhagica and rachitis, 516 
from poliomyelitis, 639 
from rheumatism, 418 
Scrofulosis (see Tuberculosis), 458 
Scrotal tongue, in Mongolism, 719 
Scrotum, absence of, 185 

tumefactions of, 164 
Scurvy, 514 
Sea-salt baths, 92 
Seborrhea capitis, 761 
Select, palatable medication, 101 
Semeiology of disease, 115 
Sepsis neonatorum, general, 226 

local, 219 
Septic arthritis, differentiated from rheu- 
matism, 418 

sore throat, 293 
Septum ventriculosum, defects in, 527 
Serum diagnosis of, syphilis, 85 

tuberculosis, 84 

typhoid fever, 86 

typhus fever, 86 
Serum, bubonic plague, 500 

diphtheria, 75 

dysentery, 414 

meningitis, 78 

pneumonia, 327 

poliomyelitis, 642 

tetanus, 77 
Seven-day-fever, 410 
Shingles (see Herpes Zoster), 767 
Ship fever, 404 
Sick room, 68 
Simon's triangle, eruption in smallpox, 

396 
Sinus thrombosis, 604 

intrasinus injections, 95 



Sinusitis, 291 

Skin diseases, 761 

Skull, semeiology of, 116 

sugar loaf shape, 708 
Sleep, 64 

"Sleeping sickness" (see Lethargic En- 
cephalitis), 625 
Smallpox (see Variola), 395 
Smell, abnormal sense of, in amentia, 701 
Snuffles, in syphilis neonatorum, 483 
Soap bath, 92 
Soor, 233 
Sore throat, 293 
"Spanish influenza," 345 
Spasmodic laryngitis, 309 
Spasmophilia, 668 

in rickets, 510 
Spasms, eclamptic, 669 

glottis, 677 

habit, 681 

nutans, 682 

rotatory, 682 

torsion, progressive, 688 

vesical, 586 
Spastic paralysis, 618, 637 

semeiology of, 167 
Speech, development of, 699, 704 
Spina bifida, 197. 597 
Spina ventosa, 472 
Spinal, curvatures, 479, 507 

hemorrhage, 655 

meningitis, 655 

paralysis, 627 

tumors, 662 
Spirochetosis, 404 
Spleen, diseases of, 556 

movable, wandering, 556 

normal, 149 
Splenic, anemia, 549 

congestion, 557 

leukemia, 550 
Splenitis, 557 

Splenomegaly, in pseudoleukemia infan- 
tum, 549 

primary, family (Gaucher type) 558 

semeiology of, 152 
Spondylitis, 462 

differentiated from cervical rib, 464 
from rheumatism, 416 
Sponging, cold and hot, in hyperpyrexia, 

89 
Spotted fever (see Typhus), 404, 410 
Sprue, 233 

Sputum, semeiology of, 138 
Starting pain, in coxitis, 469 

in spondylitis, 463 
Static current, 96 
Status idioticus, 702 
Status lymphaticus, 568 
Sterilization of milk, 51 
Sternocleidomastoid, hematoma of, 208 



796 



INDEX 



Sternum, defects of, 181 

Stiffness of neck (see Rigidity), 129, 607 

Stigmata of degeneration, 697 

still's disease, 422 
Stimulants, 108 
Stomacace, 234 
Stomach, semeiology of, 147 
capacity of, in infants, 55 
washing of, 93 
Stomatitis, 233 

treatment of, 236 
Stones in bladder, 586 

in kidneys, 578 
Stools, fat in, 38 

semeiology of, 158 
Strabismus, semeiology of, 120 
Strangulation, intestinal, differentiated 
from acute appendicitis, peri- 
tonitis and intussusception, 267 
Strawberry tongue, in scarlatina, 384 
Stridor congenitus, 180 
Struma, 561 
Strumitis, 561 
Strumous ophthalmia (see Scrofulosis), 

459 
Stuttering, as a result of adenoids, 299 
St. Vitus' dance, 378 
Sugar-cake or coated liver (Pick 's dis- 
ease), 285 
Sugar, assimilation of, 36 

faulty, 55 
Sugar-loaf-shape of skull (Oxycephaly), 

708 
Sulphur, baths, 91 
fumigation, 71 
Summer complaint (see Cholera Infan- 
tum), 250 . 
Suprarenal extract, 113 

in asthma, 339 
Surgical treatment of amentia, 749 
Sweating, excessive in, German measles, 
364 
rickets, 506 
Sydenham's chorea, 678 
Syphilis, acquired, 494 
congenital, 482 

differentiated from hydrocephalus, 712 
from rachitis, 510 
from scrofulosis, 460 
embryonalis s. fetalis, 482 
hereditary, 482 

late, 490 
neonatorum, 483 
triad of syphilis, 490 
treatment, 495 
Wassermann reaction in, 85 
Syphilitic arthritis, differentiated from 
rheumatic, 418, 421 
dactylitis, differentiated from spina 



Syphilitic — Cont'd 

laryngitis differentiated from simple 
and tuberculous laryngitis, 312 
Syringomyelia, 654 



Tabardillo (see Typhus Fever), 404 
Tabes mesentcrica, 456 
Taches cerebrales, 608 
Taenia? (see Tenia?), 278 
Talipes, 202 

paralytic, 617, 644 
Tapeworms, 278 

Taste, abnormal sense of, in amentia, 701 
Tay-Sachs' disease (see Amaurotic Fam- 
ily Idiocy), 716 
Teeth, Hutchinson's in syphilis, 490 
permanent, 124 
semeiology of, 126 
temporary, 124 
Teething, abnormal, ' 125 
difficult, 236 
normal, 124 
Telangiectasis, 777 
Tendon reflexes, 171 
Tenia?, 278 
Tepid baths, 90 

Testicles, congenital malformations of, 
193 
undescended, 195 
Tests for, acetone and diacetic acid, 524 
allergy, 87 
hearing, 306 

mental, Schick's, 74, 705, 753. 
tuberculin, 82 
Wassermann-Noguchi, 85 
Widal, 86 
Tetanism, 671 

differentiated from eclampsia, tetanus 

and tetany, 672 
resembling tetanus neonatorum, 227 
Tetanus, antitoxin, 77, 227 

neonatorum, 227 
Tetany, 673 

electricity in, 98 
Therapeutics, 88, 101 
Thigh friction, 593 
Thiosiamine, in stenosis of esophagus, 

240 
Thomsen's disease (see Myotonia Con- 
genita), 205 
Thoracoabdominopagus, 189 
Thorax, activity of, 133 
diagnostic lines of, 135 
pain on pressure of, 133 
shape of, 132 
tumefactions of, 133 
Threadworms (see Oxvuris Vermicular- 

is), 276 
Throat, diseases of, 288 
Thrombosis, sinus, 604 



INDEX 



797 



Thrash, 233 
Thymitis, acute, 566 

chronic, 563 
Thymol, specific in uncinariasis, 282 
Thymus, asthma, 568 

death, 568 

gland, diseases of, 564 

gland extract, 113, 747 
Thyroid gland, diseases of, 129, 561 

extract, 113, 746 
Tic (spasm), 681 
Tic fever, 410 
Tinea favosa, 776 

kerion, 775 

trichophvtina, capitis and corporis, 774, 
776 
Tongue, diseases of, 238 

scrotal in Mongolism, 719 

semeiologv of, 127 

tie, 177 
Tonics, 103 
Tonsillectomy, 296 

dangers of, 297, 300 
Tonsillitis, 293 

differential diagnosis of, 294 
Tonsillotomy, 296 
Tonsils, hypertrophy of, 296 

removal of, 296 

semeiology of, 128 
Top-milk, 49 

Torsion, spasm, progressive, 688 
Torticollis, electricity in, 99 

in retropharyngeal abscess, 302 

in rheumatism, 416 

tonsillitis, 294 
Touch, pain and temperature senses; ab- 
normal in amentia, 702 
Toxin-antitoxin immunization in diph- 
theria, 75, 370 
Trachea, congenital malformations of, 

180 
Tracheobronchitis, 314 
Tracheocele, 180 
Tracheotomy in diphtheria, 381 
Triad, anticostive, 263 

of syphilis, 490 

of tetany, 673 
Trichiniasis (see Polymyositis), 425 
Tricuspid valve, disease of, 540 
Trident hand, 514, 722 
Trismus neonatorum, 226 
Trousseau's sign, in meningitis, 608 

in tetany, 673 
Tuberculin, tests, 82 

therapy, 83 
Tuberculosis, 437 

abdominal organs, 453 

bones and joints, 461 

brain, 452 

bronchial glands, 444 

complement-fixation reaction in, 84 



Tuberculosis — Cont M 

genitourinary tract, 456 

intestines, 456 

lungs, 442, 444 

knee joint, 470 

lymphatic glands, 458 

meningitis, 599 

metacarpals and phalanges, 472 

miliary, 442 

peritoneum, 453 

prevention of, 437 

skin and glands, 458 

vertebral column, 462 
Tuberculous arthritis, differentiated from 
rheumatic, 421 

coxitis, 470 

dactylitis, from syphilitic, 472 

meningitis, from nontuberculous, 614 

peritonitis, from similar affections, 
154 
Tumors of, brain, 645 

bones, 476 

cord, 662 

kidneys, 582 

larynx, 313 

liver, 286 

nose, 290 

phantom, hysterical, 684 

sacrum and coccyx, 200 
Tussis, convulsiva, (see "Whooping 
Cough), 429 

in the newborn, 434 
Typhlitis, 269 
Typhoid fever, 399 

differentiated from gastroenteritis, in- 
fluenza, malaria, meningitis, 
pneumonia, Eocky Mountain 
fever, tuberculosis, typhus fever, 
402 

Widal reaction in, 86 
Typhoid spine, 401 

Typhus exanthematicus or spotted fever, 
404 

Weil-Felix reaction in, 86 



Umbilical, arteritis and phlebitis, 228 

granuloma, 222 

hemorrhage, 222 

hernia, 197 
Umbilicus, diseases of, 219 

care of, 221 
Uncinariasis, 281 

Undescended testicles (see Cryptorchid- 
ism), 195 
Urachus, fistula, 191 

persistence of, 191 
Uranocoloboma, 176 
Uranoschisma, 176 
Uremia, 575 



798 



INDEX 



Uremia — C'ont \1 

differentiated from meningitis, 613 

scarlatinal, 388 

treatment by lumbar puncture, 577 
Ureters, congenital malformation of, 192 
Urethra, congenital malformation of, 193 
Uric acid, infarct, 231 

in urine, 162 
Urinary findings, pathologic, 159, 574 
Urticaria, 764 
Uvula, semeiology of, 128 



V 



Vaccination, 72 

contraindications to, 74 

revaccination, 73 
Vaccines, bacterial, 81 

in bubonic plague, 500 

in influenza, 354 
Vaccinia, 93 

Vagina, congenital malformations of, 197 
Vaginal discharge, 164, 589 
Vaginitis, 589 
Valvular heart disease, 536 
Vapor pack, 89 
Varicella, 395 
Variola, 395 

differential diagnosis, 398 

vaccine, 72 
Varioloid, 396, 397 
Ventilation, 66 

Ventricles, communication of, 527 
Vertebral column, congenital malforma- 
tions of, 165 

disease of, tuberculous, 462 

tumors of, 166 
Vesical calculi, (see Bladder Diseases), 

586 
Vincent 's angina, 294 
Vision disturbances, semeiology of, 121, 

701 
Vitellointestinal duct, 190 
Vitamines, 114, 504, 514, 517 
Vitia cordis, 214 

acquired, 529 

congenital, 525 



Vocal resonance, semeiology of, 137 
Vomiting, cyclic, periodic, recurrent, 522 

semeiology of, 156 
Vomitus, semeiology of, 156 
Von Jakseh's anemia, 549 
Von Pirquet tuberculin test, 82, 438 
Vulva, atresia, of, 197 
Vulvovaginal discharge, semeiology of, 

164 
Vulvovaginitis, catarrhal, parasitic ( gon- 
orrheal ) and traumatic, 589 

treatment of, 593 



W 



Warm baths, 90 

Wassermann reaction in syphilis, 85 

Weakness of extremities and muscles, 

semeiology of, 167 
Weaning of baby, 59 
Weight chart, 171 
Weil's disease (see Epidemic Icterus), 

283 
Werlhoff's disease (see Purpura Hemor- 
rhagica), 554 
Wet nursing, 46 

contraindications to, 47 
Whey, 57 

White swelling, 469, 470 
Whooping cough, 429 

in the newly born, 434 
Widal's reaction in typhoid, 86 
Winckel's disease (see Hemoglobinuria), 

229 
Wolff-Eisner, tuberculin test, 82 
Woman's milk, composition of, 48 

feeding, 42 

testing of, 45 
Worms, intestinal, 276 



Yaws (see Frambesia), 496 
Yeast, autolized in Beriberi, 517 
Yellow atrophy of liver, acute, 285 
Yellow fever, 411 

prophylactic inoculation in, 412 



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